Lower gastrointestinal bleeding is a common general surgical presentation in acute and chronic settings. Vascular anomalies account for 2% of such cases and can therefore be missed. We discuss a rare vascular anomaly in one of our patients where the diagnosis was not established for a ten-year period. We describe the subsequent management and a brief review of the literature of this uncommon condition. A 60-year-old woman was seen initially in a general surgical outpatient clinic about 10 years previously with longstanding per-rectal bleeding that had always been intermittent and fresh bright red in colour. She complained of left-sided abdominal pain prior to opening her bowels and had no change in bowel habits, loss of weight or appetite. Her previous medical history included tuberculosis, an appendicectomy and a hysterectomy. Examination during her initial presentation showed second degree haemorrhoids and a rigid sigmoidoscopy to 10cm was reported as normal. She was treated with topical ointments for her haemorrhoids but re-presented with similar complaints five years later and underwent a colonoscopy that showed an inflamed mucosa at 20cm from the anal verge. Biopsies were performed from this abnormal area of suspected segmental colitis. This led to high volume rectal bleeding, necessitating an overnight stay in hospital for observation. The biopsies were reported to be histologically normal.The patient was re-referred by her general practitioner to our teaching hospital four years later with frequent episodes of large per-rectal bleeding associated with left lower abdominal pain. A flexible sigmoidoscopy booked as a routine investigation demonstrated a bulky and inflamed sigmoid mucosa . The cliThe histology demonstrated an arteriovenous haemangioma, involving the full thickness of the colonic wall from the submucosa, extending widely into the pericolic adipose tissue. The mucosal surface overlying the haemangioma was intact and appeared normal with no evidence of direct involvement or ulceration  and 5.Fet al suggested that the most logical method of classifying vascular anomalies in the gastrointestinal tract (GI) would be according to anatomic and pathophysiological principles.Our preoperative imaging identified this lesion to be an arteriovenous malformation. Histologically, the lesion was reported to be a haemangioma with arteriovenous components. The terms ‘angiodysplasia’, ‘arteriovenous malformation’ and ‘haemangioma’ have been confusingly used synonymously in the literature. A 2008 review by Regula Cavernous and capillary haemangiomas are by far the most common variants of GI haemangiomas.Reports of true colonic arteriovenous haemangiomas are extremely rare and we have only been able to identify two such reports in the literature to date.Patients suspected to have these lesions during endoscopy should undergo non-invasive imaging with either contrast enhanced CT of the abdomen and pelvis or magnetic resonance imaging (MRI) of the pelvis. This was evident in our case, where CT revealed the extraluminal vascular abnormality, enabling us to proceed with a definitive management plan. Management of this rare lesion was unlikely to be achieved endoscopically owing to its size and transmural involvement delineated on CT, therefore necessitating surgical resection.GI vascular malformations usually present as an acute emergency with massive haematochezia. In an elective setting like in our patient’s case, it required a high index of suspicion to suspect alternative pathologies to account for her longstanding recurrent bleeding. The suspicion was due to the episode of heavy bleeding following her previous biopsies and an abnormal, thickened, inflamed mucosa that was visualised during the flexible sigmoidoscopy. The use of radiological investigations such as CT or MRI should be considered in patients who develop unusual complications such as heavy bleeding following endoscopic biopsies to rule out such lesions non-invasively.


Neurilemmoma, also known as schwannoma, is an uncommon benign neoplasm that is most commonly found in the trunk and head and neck regions. The present study reports the case of a 67-year-old female with schwannoma localized in the anterior abdominal wall and analyzes the ultrasound and computed tomography (CT) imaging observations of the schwannoma. A dynamic time-intensity curve was also recorded in the study. A well-defined, elliptic low echo level, heterogeneous mass was observed during ultrasound examination. The CT scan revealed a solid, heterogeneous, low-density mass in the abdominal wall. Contrast-enhanced scans showed a heterogeneously enhanced mass during the arterial and venous phase. Centripetal fill-in was demonstrated and the mass was markedly, homogenously enhanced relative to the muscles during the delayed phase. Peak enhancement was observed during the venous phase and then slowly declined. However, the mass was hyperattenuated during the delayed phase. The lesion was completely excised and no evidence of recurrence has been identified during the 3 months of follow-up. The present study suggested that a diagnosis of schwannoma should be considered for certain patients with masses in the abdominal wall. Peripheral enhancement during the arterial and venous phases and homogeneous enhancement in the delayed phase are the significant imaging findings of a schwannoma. Neurilemmoma, also known as schwannoma, is an uncommon benign neoplasm originating from the Schwann cells in the peripheral nerve sheaths ,2. The mA 67-year-old female was admitted to the Affiliated Hospital of Nanjing University of Traditional Chinese Medicine  complaining of a disconcerting mass in the right anterior abdominal wall. A small mass had incidentally been found 10 years ago, with no restriction of movement present in the right abdominal wall. As the patient did not exhibit any evident uncomfortable symptoms, not enough attention was drawn to the lesion. Over the year prior to the present hospital admittance, the lump gradually increased in size and the patient felt soreness and suffered untimely gas pains. To acquire a diagnosis and treatment, the patient was referred to the outpatient clinic of the the Affiliated Hospital of Nanjing University of Traditional Chinese Medicine. There was no history of anergy, fever, anorexia, weight loss, trauma or surgery, and there was no family history of a similar complaint.A physical examination showed a 6×4-cm mass protruding through the right anterior abdominal wall. The mass was firm, non-tender and not fixed to the skin of the abdominal wall. All routine laboratory tests were within the normal ranges.An abdominal ultrasound examination showed a well-defined, elliptic, low echo level, heterogeneous mass just beneath the abdominal skin . The diaThe lesion was completely excised and a frozen section of the specimen was sent for histological examination. Histological examination  showed tSchwannomas or neurilemmomas are benign, encapsulated, slow-growing mesenchymal neoplasms that arise from Schwann cells and have a low malignant potential. These neoplasms can present at any age, and most commonly occur in adult females between the ages of 20 and 50 years old. Up to 20% of cases are associated with neurofibromatosis type 1 . AlthougThe majority of schwannomas arise from the nerve sheath of large peripheral nerves, occurring at the level of or below the subcutaneous fat layer . Thus, tRadiological examinations, CT or magnetic resonance imaging (MRI) can provide important information about these tumors, including the tumor site, its characteristics and its associations with other tissues. The imaging features of schwannomas are associated with its two components: Antoni type A (cellular component) and Antoni type B (myxoid component). The former consists of spindle-shaped cells that are arranged compactly in interlacing fascicles or short bundles. Antoni B schwannomas are loosely composed of reticular fibers, cysts, vascellum and the Schwann cells . AccordiAlthough MRI and CT are ideally suited to detect the tumor pathology and delineate the soft tissue and its components, the final diagnosis can only be confirmed by histopathological examination. Immunohistochemical examinations besides hematoxylin and eosin staining are required to form a differential diagnosis . Althougin situ or at a distant site, attributed to incomplete resection, has also been reported (The ideal treatment for schwannoma is complete surgical excision, and the prognosis is good , althougreported . The preIn conclusion, the present study indicates that a diagnosis of schwannoma should be considered for certain patients with masses in the abdominal wall. The observations of gradual and heterogeneous enhancement during the artery and venous phases, progressive centripetal fill-in and homogeneous enhancement during the delayed phase may be useful information for the imaging diagnosis of schwannomas.


Adenoid cystic carcinoma (ACC) or ‘cylindroma’ is a malignant tumor that often occurs in the areas of the head and neck, affecting the secretory glands and the major and minor salivary glands. The present study describes a case of a patient who presented with a posterior tongue lesion. The case is of a 71-year-old female with an asymptomatic volume growth of the posterior left tongue perceived 8 months prior, and neoplastic cells positive for c-kit. A computed tomography of the head and neck showed asymmetry of the base of the tongue, which was enlarged in the left portion. A physical examination revealed a nodule on the posterior left tongue of ~3 cm in diameter, while the cervical lymph node chain had a normal size and consistency. Surgical exeresis of the tongue lesion and cervical lymph node dissection were performed. Subsequent to surgical removal of the cancer cells and adjuvant radiotherapy, the patient showed excellent health, although the follow-up remains in progress. ACC, one of the most biologically destructive tumors of the head and neck, is locally aggressive and gives rise to distant metastases. The tongue is the place of origin in 3.4–17.1% of cases. The treatment for ACC consists of primary surgical resection with adjuvant radiotherapy. To prevent the risk for distant metastasis, it is necessary to remove the first echelon nodes and monitor the patient with a long-term follow-up. In 1859, Billroth . ACC is A 71-year-old female presented at the ‘Federico II’ University Hospital  with an asymptomatic volume growth on the posterior left tongue, perceived 8 months previously. The patient did not have a history of smoking or alcohol consumption, and had an insignificant past medical history, with the exception of type II diabetes mellitus treated with oral hypoglycemic agents. The clinical examination revealed a nodule on the posterior left tongue of ~3 cm in diameter with a similar color to the buccal mucosa, while the cervical lymph node chain had a normal size and consistency. A computed tomography of the head and neck performed with administration of contrast medium showed asymmetry of the base of the tongue, enlarged in the left portion, without visibility of areas of densitometric alteration, and a few small lateral cervical lymph nodes of ~1 cm in diameter bilaterally. A transoral exeresis of the tongue lesion emptying cervical lymph nodes at levels I–III ipsilateral to the tumor was performed. During the intervention, a tracheotomy was carried out to ensure breathing, which could be compromised by a postoperative edema of the tongue, and also left lingual artery ligation, to reduce bleeding. Histopathological analysis demonstrated a diffuse infiltration by ACC, cribriform subtype; the tumor was absent on the margins of excision and the neoplastic cells were focally positive to immunohistochemical staining for c-kit. All lymph nodes resulted as reactive. A nasogastric tube was removed 10 days after surgery.The patient then underwent postoperative radiotherapy and is currently under follow-up, demonstrating good health 12 months after the intervention.ACC is one of the most biologically harmful and incalculable tumors of the head and neck , is locaet al , a tyrosine kinase receptor involved in the growth and development of normal tissues and in certain neoplasms, has been previously identified to be expressed in ACC . Luna-Or7, a tyrol  of ACCs stain positively for epidermal growth factor receptors (EGFR) and may respond to agents that act as EGFR inhibitors .ACC presents a poor prognosis and it is therefore necessary to carry out long-term follow-up  and III.


Aneurysmal bone cysts are benign tumours that usually present in childhood. Aggressive forms have been described, which are often treated with surgery that entails major resection and reconstruction. Polidocanol sclerotherapy has recently been reported to have excellent results and promises to replace operative treatments, but its efficacy in the case of aggressive aneurysmal bone cysts has not been documented.An 18-year-old woman from Sweden presented with pain in her shoulder and a rapidly progressing cystic bone lesion. The differential diagnosis was a rare, aggressive form of aneurysmal bone cyst or a sarcoma of the proximal humerus. She was successfully treated using sequential percutaneous injections of polidocanol after exclusion of malignancy.Management of aggressive aneurysmal bone cysts has thus far relied on open surgery. We propose that non-operative treatment with polidocanol is efficient even in the aggressive form of the aneurysmal bone cyst. The latadiation –4. Most adiation –8. Healiadiation  or radioadiation , 10.Polidocanol sclerotherapy is a safe and effective treatment method , 12 thatAn 18-year-old woman from Sweden was admitted to our institution due to a painful mass in her left shoulder, discovered 2 months ago, and impairment in range-of-motion (ROM). An ultrasound examination by the admitting primary care physician revealed a vascularized tumour. During physical examination, a palpable mass was present in close proximity to her deltoid muscle. A plain X-ray examination of her left humerus showed an osteolytic lesion Figure a, until ABCs demonstrate a spectrum of clinical presentations, from the latent to the active form and finally the rare aggressive variant. The latter is sometimes extremely difficult to differentiate from telangiectatic osteosarcoma, as our case also clearly demonstrates. Referral to dedicated sarcoma centres, where clinical findings, radiology, cytology and pathology are interpreted by a multidisciplinary team offer clear advantages as far as diagnosis and therapy are concerned.The biological aggressiveness of the lesion should be taken into account when choosing therapy, the more indolent forms can be treated with minimally invasive approaches or even observed, because there is a potential of spontaneous regression. As intralesional excisions have been associated with higher recurrence rate than wide excision, most authors have relied on a more radical resection and subsequent reconstruction of the skeletal defect to treat aggressive ABCs.The presented case suggests that the non-invasive treatment with polidocanol is equally effective in aggressive ABCs, is not accompanied by side effects and seems to compare favourably to surgery. Indeed, morbidity associated to radical surgery is not negligible, time to recovery is often prolonged, and failures of the reconstruction have been reported . Other mWe suggest that polidocanol sclerotherapy be considered a treatment option for all ABCs, including the aggressive lesions. This is an important finding because it shows the applicability of a simple non-operative method for the treatment of a disease, which previously entailed open surgery with a considerable risk for side effects.Written informed consent was obtained from the patient for the 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.


Rosai-Dorfman disease (RDD) involving the cardiovascular system is extremely rare; to our knowledge, there are only 9 cases in the literature. Here, a case of a 60-year-old male with RDD involving the right atrium is presented. A comprehensive literature review was undertaken to summarize the clinical and pathologic features of this disorder.http://www.diagnosticpathology.diagnomx.eu/vs/2143194139120169.The virtual slide(s) for this article can be found here:  Rosai-Dorfman disease (RDD), first reported by Rosai and Dorfman in 1969 and originally described as sinus histiocytosis with massive lymphadenopathy, presents in its most typical form as massive, painless bilateral lymph node enlargement in the neck. This symptom is associated with fever, leukocytosis, an elevated erythrocyte sedimentation rate, and polyclonal hypergammaglobulinemia-4. We heTo date, approximately 7 months of routine follow-up after the surgery has been performed; the patient has not received any further treatment and remains well, with no recurrence.The involvement of an extranodal site in association with lymphadenopathy is present in approximately 43% of all RDD cases, and only 23% of cases show isolated extranodal RDD. The skiThe differential diagnoses of a cardiac mass with microscopic features similar to those of RDD include Langerhans cell histiocytosis (in which the cells are positive for both S-100 protein and CD1a), an inflammatory myofibroblastic tumor (which has a background proliferation of spindle cells associated with an infiltrate of mononuclear inflammatory cells and ALK-1 positivity), metastatic malignant melanoma (in which cells are positive for Melan-A), Hodgkin’s disease (which shows characteristic Reed-Sternberg cells and positivity for CD15 and CD30), and fungal or mycobacterial infections .RDD is a rare entity, and RDD with cardiac involvement is extremely rare. Doppler echocardiography, computed tomography, and magnetic resonance imaging are useful in detecting and characterizing masses but are not specific for RDD. Pathologists must be aware that RDD should be considered among the possible differential diagnoses for cardiovascular tumors.Written informed consent was obtained from the patient prior to publication of this case report and the 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.YLB and ZH were the main authors on the paper, worked up the case, and drafted the manuscript. YXM and HWW participated in the design of the study. JBY conducted the immunohistochemical study. YZ was responsible for the clinical data. XRL was the surgeon who operated on the patient and who interpreted the patient’s data. LS participated in the radiological analysis. ZHL was the main pathologist involved in the case, made the final diagnosis, and was the main editor of the body of the text. All of the authors read and approved the final manuscript.


Meckel’s diverticulum is the most common anomaly of the gastrointestinal tract. It is usually asymptomatic, but approximately 4 % present with complications such as bleeding, intestinal obstruction, and inflammation, while perforation is rare. Carcinoid or gastrointestinal stromal tumors are occasionally found in the resected specimens of Meckel’s diverticulum, particularly in the context of perforation.A 62-year-old male with a recent history of admission and evaluation for hematochezia presented with abdominal pain. His physical examination was consistent with peritonitis. Results of laboratory testing were significant for white blood cell count of 32,000/μL. CT scan of the abdomen revealed pneumoperitoneum. During the exploratory laparotomy, perforated Meckel’s diverticulum was encountered and segmental bowel resection was performed. Histological examination findings were compatible with gastrointestinal stromal tumor within Meckel’s diverticulum.While gastrointestinal stromal tumor is a rare finding in Meckel’s diverticula, the potential for the coexistence of this and other tumors suggests that segmental resection of the small bowel should be considered in the treatment of perforated Meckel’s diverticulum. Meckel’s diverticulum is the most common anomaly of the gastrointestinal tract. It is usually asymptomatic, but approximately 4 % are symptomatic with complications such as bleeding, intestinal obstruction, and inflammation . DivertiA 62-year-old Caucasian man with a recent history of admission and evaluation for hematochezia presented to the emergency department with acute-onset generalized abdominal pain. Prior medical evaluation including upper and lower endoscopy revealed no identifiable source of bleeding. He was then discharged with a capsule endoscopy scheduled as an outpatient but returned when he developed an acute-onset generalized abdominal pain. His physical examination was remarkable for peritonitis with moderate abdominal distention and guarding. His vital signs were normal except for mild tachycardia. Results of laboratory testing were significant for white blood cell count of 32,000/μL without bandemia. CT scan of the abdomen revealed pneumoperitoneum Fig. .Fig. 1CTAt exploratory laparotomy, we encountered a small amount of murky ascites and a perforated small bowel diverticulum on the anti-mesenteric side of the ileum Fig. , approxiHistological examination revealed a 4-cm, intramural spindle cell neoplasm with moderate nuclear pleomorphism Fig. , left. IHis postoperative course was uneventful. He was discharged home on postoperative day 4. Adjuvant therapy with imatinib was initiated for prevention of tumor recurrence.Perforation is an unusual clinical manifestation of Meckel’s diverticulum. Most reported cases of perforated Meckel’s diverticulum are secondary to foreign body , 3 or spThe standard surgical treatment of symptomatic Meckel’s diverticula is diverticulectomy, unless the indication for operative management is bleeding, in which case segmental resection of the ileum that includes both the diverticulum and the adjacent ileal ulcer should be performed . In addiWhile gastrointestinal stromal tumor is a rare finding in Meckel’s diverticula, the potential for the coexistence of this and other tumors suggests that segmental resection of the small bowel should be considered in the treatment of perforated Meckel’s diverticulum.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.CD, cluster of differentiation; CT, computed tomography; GIST, gastrointestinal stromal tumor; SMA, smooth muscle actin


Chordomas are rare neoplasms arising from notochordal remnants and may develop anywhere in the body while the most common anatomic site is the sacrococcygeal area. The most effective treatment of chordoma is surgery. Chordomas rarely metastasize to lung, bone, soft tissue, liver, lymph nodes, and skin. However, there is currently no standard systemic treatment for advanced stage chordoma. Here, we reported a rare presentation of chordoma patient with liver only metastases and poor prognosis. Chordomas are extremely rare primary malignant bone tumors that arise from notochordal remnants. They are usually seen in adults and occur in the fifth to seventh decades of life . The mosIn May 2009, a 62-year-old male patient was admitted with complaints of severe pain and edema in gluteal region. He had a history of cholecystectomy and pulmonary tuberculosis 3 years before. Pelvic computed tomography (CT) revealed a huge mass (15∗13 cm) infiltrating the coccyx and most of the sacrum without any regional lymphadenopathies. Chordoma of the sacrococcygeal area was diagnosed by Tru-Cut biopsy under radiological evaluation. In June 2010, the chordoma in the sacral region was excised with tumor-free margins. Afterwards, adjuvant radiotherapy was applied for about 30 days; pelvic box tumor total dose: 50 gray in 25 fractions and boost tumor total dose: 10 gray in 5 fractions. After completion of the treatment, the patient was followed up 10 Gy boost dose was applied after 50 Gy to the total dose of 60 Gy in 30 fractions. 2 Gy was applied per fraction every weekdays.A local tumor recurrence developed after about two years and required additional surgical procedures. The patient was reoperated for its tumor recurrence. Soon after the operation, during routine examination, liver function tests were found moderately high. Abdominal computerized tomography (CT) revealed multiple hypodense lesions in the liver: 17 cm mass in the right lobe, about 7 cm mass in the left lobe, and 3 cm mass in junction of the right and the left lobe of the liver . TherefoChordomas are very rare tumors arising from remnants of the primitive notochord and account for 1 to 4% of all primary malignant bone neoplasms . ChordomChordomas are locally aggressive and usually recur at the region of their origin. Heffelfinger et al. determined that the first local recurrence of these tumors resulted in most of the patients within 2 years of initial presentation in vertebral chordomas, 2.5 years for sacrococcygeal chordomas, and 3 to 4 years for sphenooccipital chordomas .Chordomas can rarely metastasize to distant sites and the risk of metastasis for chordomas is very high after radiation therapy. Most of the patients metastasize to lungs (58%) followed by 33% to the lymph nodes, 22% to the liver, 17% to bone, and 9% to skeletal muscle [Many histological studies have been carried out to determine the factors that would estimate the metastatic potential of a chordoma. Predicting factors for the metastatic potential of a chordoma include lack of intercellular material, variable cellular and nuclear size, increased mitosis, cell density, excessive intracellular mucin formation, pleomorphism, anaplasia, hyperchromatism, and invasiveness of tumor. However, these factors have also been shown in nonmetastatic chordomas. The accurate diagnosis depends on histological examination together with ultrastructure and immunohistological studies. The cytopathological hallmarks of chordomas contain dissociated and small groups of polygonal cells, along with presence of physaliphorous cells in a background of conspicuous extracellular myxoid matrix .β and c-KIT, has been shown to be active in the treatment of advanced chordoma [The most effective treatment of chordoma is surgery. It is usually difficult to obtain tumor-free margins at initial surgery, because the anatomical location of these tumors limits the ability of the surgeon to remove the entire tumor . The usechordoma . The epichordoma .We presented this case due to its uncommon presentation with isolated liver metastasis. In the literature, there is only one chordoma patient that had isolated liver metastasis. Soon after the diagnosis of metastases, the patient died which means that close follow-up of the high-risk chordoma patients is very important even after complete resection of the primary tumor. Although a lot of new molecular targeted therapies are used for advanced stage chordoma, there is currently no standard systemic treatment. Chordoma with liver metastasis still remains poor prognosis and we need new therapeutic approaches for its treatment.


We report a case of neonatal perforated appendicitis presenting with an early picture of intestinal obstruction secondary to entrapment of small bowel under inflamed appendix vermiformis. Acute appendicitis is rare in neonates. Clinical presentation is always variable and non-contributory to the diagnosis. Final diagnosis is usually confirmed during surgery, late in the course which increases the risk of morbidity [1-4]. We report a case of neonatal appendicitis (NA) presenting with intestinal obstruction and presented unusual operative findings.A 21-day-old male neonate presented with fever, abdominal distension, and vomiting for two days. He had normal perinatal history (born at term with weight of 2.3kg) with normal feeding and thriving trends. On examination, his temperature was 39˚C with peripheral cyanosis and tachycardia. Abdominal examination revealed generalized distension and tenderness. CBC showed leukocytosis (27000/µL) and CRP was 70 mg/dl. Abdominal X-ray showed few air-fluid levels. Ultrasound abdomen was unremarkable except for minimal peritoneal fluid. The patient was managed with general neonatal supportive measures and prophylactic antibiotics. Exploratory laparotomy was done on the same day of admission that revealed dilated small bowel loops and the last 20 cm of ileum was entrapped under the appendix, the tip of which was adherent with the mesentery of small bowel . The appendicular tip had a perforation as well. The bowel beyond entrapment showed signs of compromised blood supply which returned progressively to normal after releasing tip of the appendix from the mesentery. No generalized peritonitis or intra-abdominal free fluid was found. Appendectomy was performed. Patient had uneventful postoperative period and discharged in a good general condition. Histopathology of the appendix showed acute appendicitis with inflammation of the peri-appendicular tissue, with normal ganglion cells. At follow-up he is thriving well with no other complaints.Most authors relate perforation in NA to late presentation and diagnosis [4]. In contrast, the findings in the present case confirm that perforation can occur early in the process of appendicitis as also shown by cases of Khan, Gupta, and Kayastha [1-3]. Intestinal obstruction in acute appendicitis is usually attributed to local abscess or mass formation or generalized peritonitis, or it can be adhesions in late postoperative course [1-5]. In our case, there was no abscess or generalized peritonitis. Surprisingly, the short appendix fixed at its tip was entrapping small bowel through a free space between tip of perforated appendix and small bowel mesentery which led to the presentation with early signs of intestinal obstruction. This condition is scarcely reported in other age groups and termed as appendicular knot or appendicular tie syndrome . To the best of our knowledge, no such case has been reported in neonates.Source of Support: NilConflict of Interest: NoneEditorial Comment: The terms appendicular knot or appendicular tie syndrome have been attributed to the entrapment of bowel under inflamed appendix adherent at the tip with mesentery or bowel; however, appendicular band syndrome  is more appropriate term for this occurrence.


We report a case of a 58-year-old Japanese man with epithelioid-type MPM, with a left chest wall protruding tumor, who underwent extrapleural pneumonectomy and chest wall resection. Postsurgical pathology showed that surgical margins were free of mesothelioma cells. Positron emission tomography taken 5 years after surgery showed no recurrence at any site, suggesting that long-term survival could be dependent on margin-free tumor resection or that specific MPM subgroups have lower malignant potential, leading to improved survival.The online version of this article (doi:10.1186/s13019-014-0176-7) contains supplementary material, which is available to authorized users. Chemotherapy, immunotherapy, irradiation, hyperthermia, and surgery have all been applied for malignant pleural mesothelioma (MPM); however, presently, with the exception of surgery, the outcomes of these treatments are unsatisfactory. The benefit of extrapleural pneumonectomy (EPP) for MPM has been controversial since data from the MARS feasibility trial were published . HoweverTM, Chugai Pharm. Co. Ltd., Tokyo, Japan) was administered twice  intrathoracically to promote adhesion between the visceral and the parietal pleura. We decided to perform EPP on consultation with the patient, following a diagnosis of clinical T3N0M0 stage III MPM based on the International Mesothelioma Interest Group classification.A 58-year-old Japanese man was admitted with left chest pain. He worked in the electrical industry for 40 years. Chest radiography revealed left pleural effusion and a 6-cm diameter protruding tumor on the anterior chest wall. A needle biopsy pathologically confirmed epithelioid-type MPM. Computed tomography revealed direct intercostal invasion of mesothelioma between the first two ribs Figure . PreoperTwo weeks after OK-432 infusion, EPP plus mediastinal lymph node dissection, combined with chest wall resection, including the first two ribs, the pericardium, and the diaphragm, was performed via a sigmoid incision of the fifth intercostal space. The pericardium and the diaphragm were reconstructed using polytetrafluoroethylene Blood loss and the duration of surgery were 1085 g and 490 minutes, respectively. Histological analysis showed that, the mesothelioma cells reached the fascia of the major pectoral muscle invading the intercostal muscles and partially destroying the ribs. However, pathological investigation confirmed that all the surgical margins were tumor-free. In addition, microscopic findings showed the aggregation of inflammatory cells, lymphocytes, plasma cells, and histiocytes with the mesothelioma cells  has been suggested as a more feasible alternative that would confer substantial survival benefit. Lang-Lazdunski et al. [Some reports indicated that trimodality improves long-term survival . HoweverThe patient here demonstrates long-term, recurrence-free survival following EPP, with combined resection of a chest wall-invading T3 tumor, for MPM. Our case findings suggest that long-term survival could be dependent on margin-free tumor resection and that even in advanced cases, some patients with a subgroup of MPM that has lower malignant potential may have a better prognosis than others.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.YY, HM and HH are the doctors for the general thoracic surgery. YY wrote the article. YY and HM performed the surgery and assisted the post operative care. HH is the consultant of performing the study. MK assessed the pathological findings. All authors read and approved the final manuscript.


Malign diseases may mimic rheumatoid diseases. Joint involvement and leg pain are among frequently encountered symptoms particularly in the patients with leukemia. Sometimes, however, primary tumor may be asymptomatic and may mimic rheumatoid diseases because of metastasis. The present case, which admitted to our clinic with bone and joint pain continuing for 10 days and mimicking acute rheumatoid fever (ARF) and in which bone metastasis due to thymic carcinoma was detected when investigated, was presented for it is a rare condition.The present case, which admitted to our clinic with bone and joint pain continuing for 10 days and mimicking acute rheumatoid fever (ARF) and in which bone metastasis due to thymic carcinoma was detected when investigated, was presented for it is a rare condition.A 13-year-old male patient presented to the pediatric policlinic with joint swelling and leg pain that appeared 10 days ago. His history revealed that pain wakes him up at night and is remittent, spreads over his thigh and accompanied by knee pain, and that he has no history of recent infection or trauma.The results of the laboratory analyses were as follows: erythrocyte sedimentation rate 63 mm/hour, C-reactive protein 3.57 mg/dl and ASO 358 IU, and the patient was considered as ARF and admitted to the clinic for further analysis. Joint examination revealed swelling, but had no warmness or redness. Results of the analyses performed for joint pain including rheumatoid factor, anti-nuclear antibody, anti-dsDNA and other markers of collagen vascular diseases, as well as brucella and salmonella agglutination tests, were all negative. Bone marrow aspiration was normal.MRI of hip, knee and sacroiliac joint were performed. Metastases were detected in all pelvic bones being more prominent in the left side including femur neck and proximal diaphysis, in bilateral sacrum and iliac bone with the largest was 28mm in the left iliac bone; multiple round-shaped metastases located in the femur, distal tibia and proximal diaphysis with the largest was 1 cm.Contrast enhanced thoracic CT demonstrated an approximately 10 x 7.5 x 5 cm heterogeneous hypodense solid-like mass lesion in the anterior mediastinum.On PET/CT, increased FDG uptake was observed at malignancy level with a SUVmax measured to be 7 in a 76 x 46 x 49 mm mass, which completely fills the anterior mediastinum, suppresses the left lung, pushes the mediastinal structures towards to the right and posterior, and invades the sternum. And there were increased FDG uptake in various areas of the lungs.th and left 5th and 6th costae, sacrum, bilateral iliac, acetabulum, head and neck of femur, pubis, and ischium.Increased FDG uptake at malignancy level with SUVmax measured to be 8.3 in bilateral humerus, bilateral scapula, sternum, extensively in C3, C7, thoracic and lumbar vertebras, in the right 8The result of the biopsy taken from the mass with the assistance of interventional radiology came up as thymic carcinoma.The present case, which presented with the prediagnosis of ARF, is interesting because of having thymic carcinoma, is a rare condition in childhood, and no complaint other than leg pain for 10 days was present despite extensive metastasis at the time of presentation.None declared.


Epidermoid cysts are known as embryonic or acquired ectopic aberrations of the ectoderm. To the best of our knowledge, there are only a few reports of elderly onset intramedullary epidermoid cysts. We report a case of elderly onset intramedullary epidermoid cyst at the conus medullaris.A 63-year-old Japanese woman working as a farmer presented with slowly progressive gait disturbance and voiding dysfunction. A magnetic resonance imaging scan revealed an intramedullary mass lesion at L1 to L3. We diagnosed the lesion as an intramedullary spinal cord tumor. A laminectomy was performed at the level of Th12 to L3. Upon spinal cord dissection, a yellowish milky exudation erupted from the cystic lesion. We resected white cartilage-like pieces from the cystic cavity. Because the wall of the cystic lesion tightly adhered to the spinal cord parenchyma, we abandoned complete resection of the cyst wall. The pathological diagnosis was an epidermoid cyst.We propose that evacuation of the cyst contents is preferable, especially in cases with elderly onset and congenital origin.The online version of this article (doi:10.1186/1752-1947-9-7) contains supplementary material, which is available to authorized users. Epidermoid cysts are known as embryonic or acquired ectopic aberrations of the ectoderm. Spinal cord epidermoid cysts are a rare condition, accounting for 1% of spinal cord tumors. In particular, intramedullary epidermoid cysts are extremely rare [Past reports have described congenital intramedullary epidermoid cyst onset in children, adolescents and relatively young people. To the best of our knowledge, there are only a few reports of elderly onset intramedullary epidermoid cysts . Here weA 63-year-old Japanese woman working as a farmer presented with slowly progressive gait disturbance and voiding dysfunction of approximately six months’ duration. One month prior, she complained of general fatigue. She was diagnosed with chronic post renal failure caused by urinary retention. A magnetic resonance imaging (MRI) scan revealed a space-occupying lesion at the level of L1 to L3. She was subsequently referred to our institution for surgical treatment. She was medicated for mild hypertension. There was no past history of lumbar tap, myelography, spinal surgery or spinal injury.On admission, she could barely walk without holding on to a wall or table. Neurological examinations revealed bilateral muscular weakness  and numbness at her distal lower extremities. A pin-prick test showed sensory disturbance in her bilateral lower legs. A deep tendon reflex test showed hypoactivity in her Achilles tendon, without pathological reflexes. Urinary catheterization was initiated because of urinary retention. She had dyschezia, with difficulty on defecation. A laboratory analysis included complete blood analysis and biochemical examination of blood on the day of admission showed no apparent abnormalities, except for elevation of creatinine and blood urea nitrogen.An MRI scan revealed an intramedullary mass lesion extending from vertebral level L1 to L3, with mixed iso- and high-intensity change in T1-weighted images, and with isointensity change in the T2-weighted image Additional file 1:


Angiosarcoma is an extremely rare, high-grade malignancy, which accounts for <2% of all soft-tissue sarcomas. Cases of primary renal angiosarcoma represent 1% of these. Angiosarcomas involving the kidney usually originate from metastatic skin lesions or primary visceral lesions and most often occur in the sixth and seventh decades of life. The present study describes a case of primary renal angiosarcoma that presented as a large right-sided renal mass with symptoms of flank pain. Despite surgical removal of the tumor, recurrent disease with associated lung metastases was identified at the surgical site following adjuvant chemotherapy. The patient succumbed to the disease 13 months after the diagnosis. Angiosarcoma is a rare malignant neoplasm that affects the endothelial-type cells lining the vessel walls . OverallA 57-year-old male was referred to the Gayrettepe Florence Nightingale Hospital  with right-sided flank pain and hematuria. A physical examination revealed tenderness in the right hypochondrium, with otherwise normal clinical findings. The routine blood tests revealed anemia with a hemoglobin level of 10.5 g/dl . The patient underwent abdominal sonography, which identified a large right-sided renal mass and a simple cortical cyst in the left kidney. The remaining blood tests and tumor marker levels  were normal. There was no history of exposure to radiation, vinyl chloride or thorium dioxide .Computed tomography (CT) identified a renal mass measuring 14×12 cm. The lesion demonstrated heterogenous peripheral enhancement with central areas of necrosis and hemorrhage . Radiolo2 oxaliplatin and 130 mg/m2 paclitaxel  of the tyrosine kinase inhibitor, sunitinib, were administered at a dose of 37.5 mg/day. A few months later, the patient was referred to the Gayrettepe Florence Nightingale Hospital with recurrence of the right-sided flank pain. Subsequent to a physical examination, abdominal magnetic resonance imaging (MRI) and chest CT were performed. The abdominal MRI scan revealed a heterogenous contrast-enhanced necrotic mass measuring 8×9.5×12.5 cm  in the rRenal angiosarcomas are extremely rare neoplasms that originate from the normal endothelium. Overall, the lesions account for ~1% of all soft-tissue sarcomas –7. In toEarly diagnosis is challenging, as the associated clinical symptoms do not develop in the early stages of tumor growth, and the disease often progresses rapidly . MetastaThe prognosis of a patient with renal angiosarcoma depends upon the size of the initial lesion and the presence or absence of metastasis at diagnosis. Tumors measuring <5 cm in diameter confer an improved prognosis compared with those >5 cm ,12. The Local recurrence following surgery is common for angiosarcomas. In the majority of cases, metastasis is present prior to the time of diagnosis. Due to the rarity of the malignancy, it is challenging to establish a standardized treatment protocol for the local disease. Radical surgery with adjuvant chemotherapy is, at present, considered to be the optimum treatment option for angiosarcomas .In conclusion, in this study the rare case of primary renal angiosarcoma with large necrotic areas was presented, which was firstly misdiagnosed radiologically and clinically as necrotic renal cell carcinoma. The present case highlights the importance of understanding the imaging features of this rare aggressive malignancy.


A Krukenberg tumor is a rare and potentially deadly cause of elevated serum β-hCG as part of a paraneoplastic syndrome. This study aims to describe the unusual case of a 36-year-old woman that presented to the Emergency Department (ED) with back pain and a positive urine pregnancy test. Assessment revealed no intrauterine pregnancy and a small left ovarian cyst. Further investigation showed moderately differentiated gastric adenocarcinoma with distant metastases to the spine. The patient died less than 3 months after her first presentation to the ED. Paraneoplastic syndrome, albeit rare, should be considered in the differential diagnosis of elevated β-hCG due to the high mortality associated with Krukenberg tumors. Krukenberg tumor is an ovarian adenocarcinoma metastasis from a primary malignancy of the gastrointestinal tract with 76% originating from the stomach . It is b4P4 Hispanic female who presented to the ED for nausea, vomiting, diarrhea, 30 pound weight loss over 2–3 months, generalized body aches most pronounced in the lower back for 5 days, and a positive pregnancy test. Past medical history was significant for hypertension, dysphagia, 4 caesarean sections and bilateral tubal ligation. Family history was noncontributory. She denied tobacco, alcohol, or intravenous drug abuse. Physical exam revealed reproducible pain upon palpation of the spine. The bimanual exam was negative for discharge, cervical motion tenderness, or pelvic tenderness. A routine urine pregnancy test was positive and subsequent serum testing demonstrated a β-hCG level of 154 mIU/ml. The patient denied sexual intercourse in over 2 years and confirmed having a normal menstrual period less than 2 weeks prior. The patient was admitted to the hospital for further assessment and management. Initial abdominal and transvaginal ultrasound examination revealed no intrauterine pregnancy, non-visualization of the right ovary, and a complex cyst measuring 3.5 cm in diameter on the left ovary. Her repeat serum β-hCG 48 hours later was 155 mIU/ml demonstrating an insignificant change from the earlier reading. A Computed tomography (CT) scan with contrast of the thorax showed clear lungs and a cluster of enlarged lymph nodes in the celiac axis, with the largest being 1 cm. The patient was consented for laparoscopic evaluation, bilateral salpingectomy, possible left ovarian cystectomy, peritoneal washings and dilatation and curettage. At time of surgery, pelvic washings were collected and they were negative for malignant cells. Review of the pelvis revealed normal anatomy. The cyst on the left ovary was removed and sent for frozen section pathology that revealed a hemorrhagic corpus luteal cyst. The uterine curretings were also sent for frozen section pathology that showed late secretory endometrium and no chorionic villi. The patient had a normal postoperative course and was discharged from the hospital on the first postoperative day.We present the case of a 36 year old GUpon discharge, her serum β-hCG level was 175 mIU/ml. The final pathology report on the left corpus luteum cyst located a small focus of moderately differentiated adenocarcinoma in corpus luteum staining strongly positive for Cytokeratin 7 (CK7) and negative for Cytokeratin 20 (CK 20) suggesting a primary gastric or pancreatic carcinoma. The patient was referred to the oncology service. Magnetic resonance imaging (MRI) of the pelvis/abdomen demonstrated left para-aortic and paraceliac adenopathy, likely metastatic in nature. No discrete masses were seen in the ovaries. Bone scan showed enhancement in the right pedicle of L3 vertebra highly suspicious for metastasis. At this point, the patient reported increasing abdominal and back pain. Her laboratory investigation was significant for CA-125 of 134 U/ml (reference range: 0.0-21.0), CEA level of 37.2 ng/ml (reference range: 0.0-10.0), and CA 19–9 3230 U/ml (reference range: 0–37). Computed tomography (CT) guided fine needle aspiration and core biopsy of the L3 vertebral body were positive for malignant cells of poorly differentiated metastatic carcinoma, strongly positive for β-hCG, α-inhibin, and human placental lactogen (HPL). Multiple biopsies collected at colonoscopy and esophagogastroduodenoscopy showed a poorly differentiated adenocarcinoma in the lamina propria of the stomach fundus positive for AEI/3, CD7, CK20 and CEA (Figure Therapeutic intervention with chemotherapy was contraindicated as the patient was found to have urosepsis. A repeat CT abdomen/pelvis showed widely metastatic gastric adenocarcinoma with possible compression of cauda equina at L3 and metastases to the liver, spleen, left adrenal, and left acetabulum Figure . In addiKrukenberg tumor is a rare metastatic signet ring cell tumor of the ovaries that accounts for 1-2% of all ovarian tumors . The stoIn this case, the patient presented with non-specific gastrointestinal complaints such as nausea, vomiting, diarrhea, low back pain, and a 30 pound weight loss over 2–3 months. The patient had a positive β-hCG despite having a normal menstrual period 2 weeks prior and lack of sexual intercourse in over two years as well as a prior bilateral tubal ligation. Typically, after a positive urine pregnancy test, a rise in serum β-hCG of >66% in 48 hours is highly suggestive of intrauterine pregnancy . Transvaβ-hCG is a hormone glycoprotein composed of an alpha and beta subunit. β-hCG is normally produced by placental syncytotrophoblast however, it can also be produced by other tissues such as the testis, liver, lung, colon, and stomach . TherefoPhysicians should be aware that elevated β-hCG can be found in conditions outside of pregnancy and can be associated with malignancy. When persistently low levels of β-hCG are detected, a Krukenberg tumor should be considered in the differential diagnosis after excluding more common etiologies. Only 25-30% of patients with Krukenberg tumor have a primary malignancy when the Krukenberg tumor is found . DetaileAll patient information used in the manuscript were de-identified and anonymised therefore no consent form was necessary.ED: Emergency Department; hCG: Human chorionic gonadotropin; CT: Computed tomography; MRI: Magnetic resonance imaging; CK7: Cytokeratin 7; CK 20: Cytokeratin 20; HPL: Human placental lactogen.The authors declare that they have no competing interests.DM drafted the manuscript and was the corresponding author. AAH followed the patient during hospitalization and performed the surgical intervention and has given final approval of the version to be published. OAH has performed edited the manuscript for language and grammar. All authors have read and approved the final manuscript.


However, to the best of our knowledge, accumulation of 18F-FDG has not been reported in lumbosacral intraspinal IPT. Herein, we report a case of IPT in the epidural space of the lumbar spine, using the imaging findings of 18F-FDG positron emission tomography-computed tomography (PET/CT) and contrast-enhanced magnetic resonance imaging (MRI). This is the first case of IPT in the epidural space, depicted by 18F-FDG PET/CT, which revealed a homogeneous, intense 18F-FDG uptake.An inflammatory pseudotumor (IPT) is a rare benign lesion, characterized by non-neoplastic proliferation of inflammatory cells and presence of intermingling collagen fibers. IPT commonly occurs in the lungs and orbita, while an intraspinal IPT is extremely rare. IPT can mimic both clinically and radiologically malignant processes, and making a definitive preoperative diagnosis is often difficult. Recently, 18-fluorine fluorodeoxyglucose ( Inflammatory pseudotumor (IPT) is a benign tumor-like lesion of unknown etiology, which has been identified in very small numbers at various locations throughout the body. It is mostly found in lungs with extrapulmonary occurrences at sites including the orbit, nasal sinuses, liver, spleen, pancreas, intestine, kidney, urinary bladder, testis, heart, and lymphatic system .To date, the appearance of IPT in the spinal canal has been extremely rare. This condition has been successfully treated by surgical removal, steroid therapy, and radiation therapy to the residual mass . It is d18F-FDG) positron emission tomography-computed tomography (PET/CT).Herein, we present the first case of epidural IPT in the lumbar spine, using 18-fluorine fluorodeoxyglucose  for the detection of primary cancer and metastatic disease. The imaging showed intense uptake of FDG with maximal standardized uptake value (SUVmax) of 6.7 in the right epidural space (There was no evidence of adjacent bone destruction or bony sclerosis on CT or MRI images. The differential diagnoses included spinal epidural malignancies, such as spinal lymphoma, metastatic tumor, or epidural abscess. The patient underwent al space . There wWe performed an L5-S1 hemilaminectomy and microscopic subtotal resection of the mass, which was located in the epidural space inside the ligamentum flavum. The mass was highly hypervascular and firmly attached to the dura, the ligamentum flavum, and the bone. Histologically, the tumor consisted of infiltrated inflammatory cells including lymphoplasma cells, neutrophils, and eosinophils in a background of stroma, composed of myofibroblasts and collagen bundles .Immunohistochemical staining showed < 2 IgG4-positive plasma cells per high power field, and the tumor was diagnosed as an inflammatory pseudotumor. After surgery, the patient started steroid therapy and his pain and neurologic symptoms steadily improved.IPT, which is synonymous with inflammatory myofibroblastic tumors, is a rare benign tumor with unknown pathogenesis. Clinical features and imaging findings of IPT are similar to those of malignant tumors. This tumor consists of a background proliferation of spindle-shaped mesenchymal cells, associated with a variable infiltration of inflammatory cells.18F-FDG PET/CT findings.IPT most commonly involves the lungs and orbita, but it has been reported to occur in nearly every site in the body . Althoug18F-FDG PET/CT. The clinical and imaging characteristics of IPT are non-specific, since the lesion has a wide range of clinical and imaging presentations. Hence, the diagnosis of IPT can be made only after other specific disorders are ruled out. Commonly, the differential diagnoses considered in spinal IPT cases include spinal lymphoma, metastatic tumor, and multiple myeloma (The current case is the first report of an epidural IPT in the lumbosacral spine, which showed a high uptake of FDG, as detected by Radiologically, IPT appears as a solid intraspinal tumor. On MRI images, IPT usually has a low signal intensity on both T1- and T2-weighted images, which may reflect the fibrotic nature of these lesions. Contrast-enhanced MRI may show a homogeneous or heterogeneous lesion and delayed imaging often shows increasing enhancement due to the presence of fibrosis .18F-FDG PET/CT. However, as in our case, marked increase in FDG uptake has been already reported as a feature of IPT (To our knowledge, there have been no reports on intraspinal IPT with e of IPT -16. It iThe mechanism of high FDG uptake in IPT may be related to inflammatory cells in the pseudotumor . As neut18F-FDG PET/CT; therefore, without a biopsy, making a differential diagnoses is very difficult. However, 18F-FDG and 18F-FDG PET/CT have been reported to be useful in evaluating the therapeutic effects of steroid or radiation therapies on IPT in cases with incomplete surgical resection (It is impossible to distinguish malignant neoplasms from inflammatory pseudotumors based on imaging findings of MRI and esection , 18.Surgical excision is usually mandatory in IPT, compressing the spinal cord, due to the emergent need to relieve the mass effect; it is generally curative when total excision is performed. Radiotherapy, systemic steroid, or immunosuppressive drugs are also administered for IPT patients, which may lead to a decrease in the mass volume , 19, 20.


Arthroscopic technique for lateral release is the most widely used procedure for the correction of recurrent dislocations of the patella. In the relevant literature, several complications of lateral release are described, but the spontaneous patellar tendon rupture has never been suggested as a possible complication of this surgical procedure. Patellar tendon rupture is a rather infrequent and often unilateral lesion. Nevertheless, in case of systemic diseases  that can weaken collagen structures, bilateral patellar tendon ruptures are described. We report a case of a 24-year-old girl with spontaneous rupture of patellar tendon who, at the age of 16, underwent an arthroscopic lateral release for recurrent dislocation of the patella. This is the first case of described spontaneous patellar tendon rupture that occurred some years after an arthroscopic lateral release. Patellar tendon ruptures are often associated with lupus erythematosus, rheumatoid arthritis, chronic renal disease, or chronic use of corticosteroids. Bilateral patellar tendon ruptures are extremely rare and have only been documented in some case series , 2.In the present report we describe a case of unilateral spontaneous rupture of the patellar tendon in the absence of concomitant local or systemic diseases or steroid use.We describe the case of a 24-year-old girl who, at the age of 16, underwent a lateral release arthroscopic surgery of the right knee for recurrent dislocations of the patella. She was asymptomatic for two years; then she reported a new dislocation of the patella that she reduced on her own. She was hospitalized and conservatively treated for the pain and swelling of the knee and then continued with physiotherapy for some months. After 6 years, without any new injury, she came to our hospital for a consultation, presenting a lack of the normal anatomy of the right knee . Her actThe patient did not accept our suggestion for a surgical approach because she did not complain about important functional deficits.The patellar tendon normally has a strong structure. Some biomechanical studies reported that a force of 17.5 times the body weight is necessary  to causeThe acute rupture is due to a contraction of the quadriceps muscle against a fixed structure or to a sudden increase in the loading on the patient, against a quadriceps in active contraction; in both cases there is an eccentric contraction of muscle fibers with a muscular stretching during the contraction.Spontaneous rupture of patellar tendon is an infrequent disease. The exact epidemiology is not really known because of the lack of patients that undergo examination and that cannot be perfectly identified and treated. The bilateral patellar tendon rupture is even less frequent and only a few cases were described in the literature , 2, 5, 6Inflammatory problems, collagen necrosis, and amyloid deposits can weaken the tendon structure, thus becoming predisposing factors of the injury. Frequent tenosynovitis and microtraumas can produce a local stress with progressive tendon degeneration. Spontaneous tendon injuries are often preceded by histopathologic degenerations that can compromise the tendon integrity  and prodSpontaneous rupture of patellar tendon can occur also after a bursectomy procedure .In our case, the previous lateral release and the lack of new injuries and of systemic diseases led us to think of a possible consequence of the previous surgical procedure. The young patient had undergone a lateral release for recurrent dislocation of the patella 8 years before. Given the absence of immunologic and systemic diseases, we can presume a consequentiality in the two events, even after some years. Many authors reported successful short-term results after a lateral release. Aglietti et al.  comparedLateral release is often a quick procedure, performed arthroscopically. Nevertheless some complications can occur, such as excessive bleeding and subcutaneous lesions . The extOur case report underlines that it is mandatory to avoid extensive arthroscopic lateral release in order to minimize patellar tendon degeneration. Furthermore, patients should be informed of a potential risk of the arthroscopic lateral release, as the case presented in this paper.In conclusion, we report a rare case of spontaneous patellar tendon rupture in the absence of systemic or local disease or steroid usage. Recurrent microtraumas for daily activity and previous surgery for extended lateral release may have contributed to degenerative changes and late failure of patellar tendon.


A gastric diverticulum is a pouch protruding from the gastric wall. The vague long clinical history ranging between dyspepsia, postprandial fullness, and upper gastrointestinal bleeding makes this condition a diagnostic challenge. We present a case of large gastric diverticulum that has been diagnosed during clinical investigations for suspected cardiovascular issues in a patient admitted at the medical ward for syncope. A 51-year-old man presented to the medical department due to a syncopal episode occurring while he was resting on the beach after having his lunch, with concomitant vague epimesogastric gravative pain without any other symptom. A diagnosis of neuromediated syncopal episode was made by the cardiologist. Due to the referred epimesogastric pain, an abdominal ultrasound scan was carried out, showing perisplenic fluid. A CT scan of the abdomen was performed to exclude splenic lesions. The CT scan revealed a large diverticulum protruding from the gastric fundus. The upper gastrointestinal endoscopy visualized a large diverticular neck situated in the posterior wall of the gastric fundus, partially filled by undigested food. The patient underwent surgery, with an uneventful postoperative course. Histologic examination showed a full-thickness stomach specimen, indicative of a congenital diverticulum. At the 2nd month of follow-up, the patient was asymptomatic. A gastric diverticulum (GD) is a pouch protruding from the gastric wall, first described by Moebius in 1661 and later by Roax in 1774 . It is aA 51-year-old Caucasian policeman was admitted at the medical department of the University of Cagliari Hospital  due to a syncopal episode occurring while he was resting on the beach after eating his lunch, with concomitant vague epimesogastric gravative pain without any other symptoms. In the anamnesis he reported a previous similar episode, occurring 10 years earlier, during a walk in a shopping center after having a carbonated beverage (cola). For this reason, he underwent cardiovascular and neurological investigations. The electrocardiogram, echocardiogram, and stress test on the treadmill were unremarkable. The head-up tilt-table test reproduced the original symptoms, with objective evidence of a sudden drop in blood pressure without a decrease in heart rate. Therefore, a final diagnosis of neuromediated syncopal episode was carried out. Due to the referred epimesogastric pain, an abdominal US scan was carried out, showing a small amount of perisplenic fluid. A CT scan and an MRI scan of the abdomen were performed in order to exclude splenic lesions. The CT scan revealed a large diverticulum of the size of 52 × 68 × 72 millimeters protruding from the gastric fundus showing tight adhesions with the inferomedial surface of the spleen, the ipsilateral adrenal gland, and the upper posterior surface of the body and tail of the pancreas   situated in the posterior wall of the gastric fundus. After further exploration, a pouch partially filled by undigested food was discovered . Due to Ethicon) . The patAccording to the hypothesis suggested by Schmidt and Walters, GD can by classified into congenital and acquired types, with congenital types being more common , 7, 8. ABeing a rare and mostly asymptomatic condition, a high clinical index of suspicion is needed to diagnose and effectively manage patients with GD . When syGD is considered as a great mime: Palmer found that in 30 of 49 symptomatic patients with GD the symptomatology was ascribable to other gastrointestinal diseases .Our patient presented with postprandial loss of consciousness, with no remarkable cardiogenic problem proved. Carbonated beverages ingestion, as reported by the patient before his first syncopal attack, and the presence of eructation have already been involved with the triggering in some cases of neuromediated syncope . MoreoveIn the majority of cases GD are incidental findings during the investigation of their common symptoms. The condition can be diagnosed by endoscopic or radiological examinations. Upper gastrointestinal contrast radiographic studies, as well as oesophagogastroduodenoscopy, are the most performed diagnostic investigations. However, it is worth emphasizing that, especially in case of diverticulum with a narrow neck, they can give false negative results. Indeed, as reported by Palmer in his review, 5% of GD are missed during contrast radiographic study .Upper gastrointestinal endoscopy is the gold standard investigation to achieve a precise diagnosis. It useful not only to confirm the location and the size of the pouch, but also to perform a biopsy if a concurrent pathology is found. This diagnostic tool may be able to reproduce symptoms with distension of the diverticulum, indicating which patients would benefit from a resection , 12.More authors have reported their experience on the use of CT scan as part of the diagnostic work-up for patients with gastric diverticulum. However, CT and/or MRI findings in GD have been published only as case reports in the literature , 26–28. The appropriate treatment for both symptomatic and asymptomatic GD is still a matter of debate. It is well documented that there is no specific therapeutic strategy for asymptomatic diverticula , 20.Although Proton Pump Inhibitors (PPIs) have been suggested to alleviate the vague symptoms of gastric diverticulum, this treatment is not able to resolve the underlying pathology. Endoscopy can play an important role in the management of active upper gastrointestinal bleeding due to GD, as reported by Chen et al. . SurgicaAlthough GD remains a rarity in the etiology of abdominal pain, a high index of suspicion should be kept in mind for patients with a long history of vague upper abdominal pain and dyspepsia, especially when not subsided with PPIs and when all other more common diseases, such as gastritis and gastric cancer, have been ruled out.


Agreement between the pathologist and an experienced orthopaedic surgeon was very good while it was fair between the pathologist and a junior orthopaedic surgeon. MRI should be considered as a tool to give quick information about the adequacy of margins and to help the pathologist to focus on doubtful areas and to spare time in specimen analysis. But it may not replace the pathological evaluation that gives additional information about tumor necrosis. This study shows that MRI extemporaneous analysis of a resection specimen may be efficient in bone tumor oncologic surgery, if made by an experienced radiologist with perfect agreement with the pathologist.In 12 patients operated on for bone sarcoma resection, a postoperative magnetic resonance imaging of the resection specimens was obtained in order to assess the surgical margins. Margins were classified according to MRI in R0, R1, and R2 by three independent observers: a radiologist and two orthopaedic surgeons. Final margin evaluation  was assessed by a confirmed pathologist. Agreement for margin evaluation between the pathologist and the radiologist was perfect ( As most of these tumours are very close to major nerves or vessels, a meticulous preoperative planning is essential in order to spare these structures. Surgeons currently rely on tumour delineation by magnetic resonance imaging (MRI) to plan the surgery.Complete surgical resection remains the gold standard management for bone and soft tissue sarcomas , 2. DuriPostoperatively, the pathologist assesses the achieved surgical margins through rigorous microscopic evaluation . The goaSpecimens were obtained from 12 patients, with a median age of 16.5 years (9 to 65 years), operated on for bone sarcoma resection between January 2010 and November 2012 . InclusiPreoperative MRI of the bone tumor had been obtained in all cases in the month prior to surgery, on average 11 days (1–28 days) before surgery. Axial T1- and T2-weighted images, coronal proton density weighted images with fat saturation, and axial and sagittal T1-weighted images with gadolinium enhancement were obtained. in sano resection with adequate safe margins . For pelvic specimens, the specimen was oriented with scout view to obtain the same slicing compared to the preoperative imaging. The MRI acquisition parameters used for the specimens were specified as follows: reconstruction matrix 176 × 176, section thickness 0.5 mm, and spacing between slices 0.5 mm. The specimens' sequences were saved in DICOM format prior to analysis with the picture archiving and communication system . MRI of resected specimens was made postoperatively in the hour following the specimen resection in all but one patient due to MRI unavailability. Specimen MRI was blindly analyzed and classified by three independent observers according to the standardized classification, created by the Union for International Cancer Control (UICC) .The method of determining surgical margins is now fairly standardized , 7. The κ = 1, very good with κ between 0.8 and 1, good with κ between 0.6 and 0.8, moderate with κ between 0.4 and 0.6, fair with κ between 0.2 and 0.4, and poor with κ less than 0.2 [The margin classification by the pathologist was considered as the golden standard and was compared with the margin classification obtained by MRI (by the three independent observers) . The datResults of the margin classification by the pathologist and by imaging are listed in Three patients had R2 resection margin at the pathological evaluation. Adjuvant radiotherapy was performed in these patients. Two of them were deceased at the latest follow-up while the third had a good response to chemotherapy and is still alive without evidence of disease.κ = 1). Agreement between pathologist and experienced orthopaedic surgeon was very good while it was fair between pathologist and junior orthopaedic surgeon  or an experienced orthopaedic surgeon (used to oncologic sarcoma surgery). There was a perfect agreement between the pathologist and radiologist and a very good agreement between the pathologist and experienced orthopaedic surgeon. On the contrary, MRI interpretation by the inexperienced surgeon is not recommended, as the agreement is fair.MRI could be more rapid than histopathology to give a R classification as MRI could be obtained quickly after tumor resection (it takes 45 minutes) and final pathological evaluation is generally not obtained before 1 or 2 weeks in case of bone sarcomas. Nevertheless, MRI may not replace pathologic evaluation of the specimen, as the pathologist will give the final evaluation of the margins and information about the percentage of tumor necrosis.A theoretical benefit of this procedure could be a direct peroperative margin evaluation by rapid MRI acquisition of the freshly resected specimen. If the MRI is available and if the surgical reconstruction procedure following resection takes several hours, a rapid assessment of the resection margin could be obtained before the end of the surgical procedure, allowing the surgeon to do recut in the region where the MRI assesses an unsafe margin. It would be even possible for the radiologist to come to the operating theatre to show and explain his analysis of the MRI to the surgeon. However, this is not always possible in clinical practice.The residual tumour classification or R classification may be used after surgical treatment alone, after radiotherapy alone, after chemotherapy alone, or after multimodal therapy . It was This study has some limitations. All the histologic classification analyses were performed by one observer and one time. Only twelve patients were included in the study. Other experimental studies on animals should show quantitatively the efficiency of margin evaluation by MRI.MRI evaluation may not replace the pathological evaluation as it remains the gold standard and gives information about tumor necrosis. Nevertheless, it should be considered as a tool to give quick information about the adequacy of margins and a tool to help the pathologist to focus on doubtful areas. This could help the pathologist to spare time in specimen analysis.This study shows that extemporaneous analysis of a resection specimen may be efficient in bone tumor oncologic surgery, if made by an experienced radiologist with perfect agreement with the pathologist.


The objective of this study is to determine and discuss the causes of a giant endometrial polyp in a postmenopausal woman without hormone/drug use and to submit interesting clinical presentation. Here we report a seventy-year-old female patient who was admitted to our hospital with lower back pain. There were no other complaints from her. Physical examination was normal. For further examination, computed tomography was performed and a heterogeneous mass, with a diameter of 10 × 9 centimeters, was detected in the uterine cavity. Hysterectomy because of suspected endometrial cancer was performed. Histopathological examination showed us a giant endometrial polyp with edematous and focal fibrotic stroma, large thick walled blood vessels between normal sized and cystically dilated endometrial glands. To the best of our knowledge, this is the first report of a giant endometrial polyp which is unrelated to use of drugs such as tamoxifen and raloxifene; however, based on the history of the patient it may be associated with long-term consumption of thyme, which is a kind of phytoestrogen.  Endometrial polyps are localized overgrowth of endometrial glands and stroma through the uterine cavity. This benign disease affects 25% of women . They prThe prevalence of malignancy with endometrial polyps is 1–3% . The risDevelopment of endometrial polyps is affected by unbalanced estrogen therapy, estrogen-like effect, and unbalanced estrogens and progestins. Many estrogen mimics are produced by plants (phytoestrogens (PEs)). PEs are found abundantly in foods, herbs, and spices commonly consumed by humans. It is reported that ER-binding herbal extracts are agonists, much like estradiol; however, PR-binding extracts are neutral or antagonists .Here we presented a giant endometrial polyp in a postmenopausal woman without vaginal bleeding and hormone or drug use. As interesting as her clinical presentation, she had long-term consumption of thyme, which is a kind of PE. Through this rare entity, we discussed the effects of PEs on the female genital tract.A seventy-year-old female patient, G7P7, was admitted to our hospital department of orthopedics with lower back pain. She did not have any other complaints. In the history of the patient, there was only a cholecystectomy history which was performed 26 years ago. Drug use, especially hormone derivatives, was not available, but the patient described consumption of thyme tea by the amount of 1-2 cups a day in the long term, approximately 20–25 years. Orthopedic physical examination was normal; for further examination computed tomography was performed and a heterogeneous mass, with a diameter of 10 × 9 centimeters, was detected in the uterine cavity, whereupon the patient was referred to the department of obstetrics and gynecology. The lesion was asymptomatic and unassociated with vaginal bleeding. Physical examination showed distorted cervix, and because of this preoperative sampling for histopathological diagnosis could not be made. Surgical procedure was planned and hysterectomy because of suspected endometrial cancer was performed. Intraoperative pathology consultation was requested. Accordingly, the mass lesion was reported to be compliant with endometrial polyp, however necessity of multiple sampling was noted.Macroscopic examination showed us a giant pedunculated polypoid lesion that was extending into the uterine cavity and filling it, with a smooth surface, which is 10 × 9.5 × 7 centimeters in diameter. Cut surface of the polypoid lesion was composed of partially cystic spaces and solid areas, edematous stroma, small foci of fibrous areas, and haemorrhage. The lesion had a soft consistency but it was not degradable .Many sections were taken from the specimen. In microscopic examination, intact large polypoid tissue with cystically dilated glands lined by a single layer of flattened epithelium, large thick walled blood vessels, fibrous stroma with spindled fibroblast-like cells, abundant extracellular connective tissue, and more typical endometrial glands was seen .Giant endometrial polyps are uncommon variants of classical polyps. Until today only a few cases are reported in the literature and they were associated with tamoxifen and raloxifene treatment –5. EndomIndraccolo et al. studied the pathogenesis of endometrial polyps and they demonstrated a causative link: ageing, bcl-2 expression, obesity, tamoxifen regardless of timing, relationship between estrogen receptors and progestins, unbalanced estrogen therapy, estrogen-like effect, and unbalance between estrogen and progestins . Verbena. In general, they found that ER-binding extracts are agonists, much like estradiol, whereas PR-binding extracts are neutral or antagonists [PEs are the natural source of estrogen which have been demonstrated by their affinity for the estrogen receptors. PEs are plant-derived compounds that are very similar to estrogen. However, they have shown estrogenic and antiestrogenic activity depending on concentration, endogenous estrogen concentration, and menopausal status. Zava et al. reported that the six highest ER-binding herbs are soy, licorice, red clover, thyme, turmeric, hops, andagonists . Endometagonists . Chandraagonists .Endometrial aromatase activity and gene mutations are associated with endometrial polyp development. However, genistein, which is a kind of PE, can increase aromatase activity in endometrial stromal cells .We reported a case of asymptomatic giant endometrial polyp which was unassociated with drug use, especially hormone derivatives, such as tamoxifen. However, our patient described long-term consumption of thyme which is a kind of PE. She has used the amount of 1-2 cups of thyme tea a day over 20–25 years. We could not detect any other relations with the pathogenesis of giant endometrial polyp. As is known, thyme is a PE and PEs can act like estrogen and this can lead to uterine pathologies, like endometrial polyp. In the literature the effects of PEs were shown in some studies, but the pathophysiology was not fully understood.In summary, the origin and pathogenesis of endometrial polyps are not fully evaluated. Giant endometrial polyps are rare entities and they are associated with tamoxifen and raloxifene treatment. Endometrial polyp development is depending on estrogen stimulation and unbalanced estrogen. PEs, such as thyme, are plant-derived compounds and they are associated with uterine pathologies. To the best of our knowledge, this is the first report of a giant endometrial polyp which is unrelated to the use of drugs such as tamoxifen and raloxifene; however, based on the history of the patient it may be associated with long-term consumption of thyme, which is a kind of PE.


Brief background: Oroantral communication (OAC) is the space created between the maxillary sinus and the oral cavity, which, if not treated, will progress to oroantral fistula (OAF). Several methods of surgical OAC repair have been described, but only a few have gained recognition.Materials and methods: A 13 years old male child patient with complaint of difficulty in drinking water and change in voice diagnosed as OAF managed with closure with buccal fat pad (BFP).Discussion: Oroantral fistula is an abnormal communication resulting most frequently from extraction of the upper posterior teeth. Many techniques have been proposed for the closure. The preferred technique may vary from one surgeon to another.Conclusion: The adequate availability of BFP in children, effortless mobilization excellent blood supply and minimal donor site morbidity make it a perfect flap for OAF closure in pediatric patient.How to cite this article: Agrawal A, Singhal R, Kumar P, Singh V, Bhagol A. Treatment of Oroantral Fistula in Pediatric Patient using Buccal Fat Pad. Int J Clin Pediatr Dent 2015;8(2):138-140. This post-extraction complication occurs more likely if there is preexisting periapical anomaly associated with the offending tooth near the maxillary sinus or extraction of maxillary molar teeth with widely divergent roots. Other causes of OAC include destruction of a portion of the sinus by cysts or benign or malignant tumors, dentoalveolar or implant surgery, etc.4Oroantral communication (OAC) is the space created between the maxillary sinus and the oral cavity, which, if not treated, will progress to oroantral fistula (OAF) or chronic sinus disease.5 Larger openings do not heal spontaneously and necessitate a surgical procedure to close the resulting oroantral opening.Maxillary sinus perforations less than 5 mm close spontaneously after the development of a blood clot in the socket.6 in 1977 for the closure of OAC and oronasal communication.Several methods of surgical OAC repair have been described, but only a few have gained world-wide recognition. In recent years, the use of a pedicled buccal fat pad (BFP) in closure of large oroantral defects has become popular. It was first described by EgyediBecause of the smaller volume of the sinus, the risk of the occurrence of OAC in children and adolescents is less. Hereby, we are reporting a case of closure of OAF by BFP in a 13 years old male child which is a rare occurrence.A 13 years old male child reported to the department of pedodontics, PGIDS, Rohtak with chief complaint of difficulty in drinking water and change in voice since 1 month. Patient gave history of traumatic removal of his right upper back tooth (due to caries) 1 month back following which these problems started. On examination, his right maxillary permanent first molar was missing, there was slight opening on the buccal side of the alveolar process. There was nasal discharge of oral fluids along with nasal twang. Diagnosis of OAF was made  and 2. PManagement: His maxillary antrum was irrigated with normal saline three times within a week. After taking informed written consent for the surgery and getting necessary blood investigations, closure with BFP under local anesthesia was planned. Right posterior superior alveolar nerve block and greater palatine nerve block was given with 2% lignocaine with 1:200000 adrenaline along with the right buccal vestibule infiltration. The mucoperiosteal flap was raised from mesial to 15 to distal to 17 with molt’s periosteal elevator after giving incision with no. 15 blade. The defect . An unusual visible change in facial contour has been reported in patients only when the BFP is used for reconstruction of large defects. In our case no such complication occurred.Recently, the use of a pedicled BFP in closure of large oroantral defects has become popular. In our case, the OFA was closed with BFP. Anatomically, the BFD has a central body and four processes: buccal, pterygoid, pterygopalatine, and superficial and deep temporal.13 used the fat pad as an uncovered pedicled graft with no skin graft and saw complete epithelialization in approximately 2 weeks. They also advised that to diminish the incidence of postoperative complications, the fat pad graft should sufficiently cover the surgical defect and that it should not be sutured under tension. Patient should receive a soft non-chewy diet until healing has taken place. In our case, the fat pad was secured with the vicryl suture and then covered with the buccal flap.Egyedi recommended securing the fat pad with catgut sutures and then covering the graft with a split-thickness skin graft. Tideman et alWhile choosing the surgical treatment of an OAF, its location and size, relation to neighboring teeth, duration, existence of inflamed sinus and the general health status of the patient should be taken into consideration. The adequate availability of BFP in children, effortless mobilization of the BFP and its excellent blood supply and minimal donor site morbidity make it a perfect flap for OAF closure in pediatric patient.


Introduction. The incidence of gallbladder cancer presenting with acute cholecystitis is 2.3%, squamous cell carcinoma is rarely seen, and overlap of acute cholecystitis and squamous cell carcinoma is a very rare condition in the literature. Presentation of Case. A 75-year-old woman was admitted to emergency service with a pain in the right upper quadrant, nausea, and vomiting. The patient was considered as having acute cholecystitis. During the exploration because Hartman's pouch was not dissected, it was adhered to the cystic duct and had fibrotic adhesion. It could not be understood whether this adhesion was a tumor or a fibrotic tumor and thus we performed cholecystectomy with a 1 cm resection of the choledochus. Pathological examination revealed the presence of (R0), T1 N0 M0 squamous cell carcinoma with clean resection borders and there was no in tumor five dissected lymph nodes. The patient has been followed up for about two years and no clinical problem has been observed throughout the follow-up. Discussion. Acute cholecystitis with gallstones may overlap with gallbladder cancer and generally presents nonspecific symptoms. No additional imaging techniques were performed since no clinical sign except for the wall thickening was detected and no suspected malignancy such as mass was detected on USG. Squamous cell carcinoma of the gallbladder shows poor diagnosis, but since its overlap with cholecystitis presents early symptoms and thus leads to early diagnosis and effective treatment, the localization of the carcinoma is of prime importance. Conclusion. Gallbladder cancer should be kept in mind in elderly patients with acute cholecystitis. Acute cholecystitis with gallstones is the most common surgical problem of the gallbladder. The incidence of gallbladder cancer presenting with acute cholecystitis is 2.3% , 2. AmonGallbladder cancers, comprising 90% adenocarcinoma and 0.5–3% squamous cell carcinoma (SCC), account for 3-4% of all malignant tumors. SCC is more common at advanced ages and the female to male ratio is 1/2 –9. SCC pEarly diagnosis of SCC accounts for 10–50% of the cases. Ultrasonography (USG) is the method of choice in the diagnosis but advanced techniques such as tomography are also used, particularly for the suspected cases. In the diagnosis of gallbladder cancer, the sensitivity of USG is 34%, whereas it is ~40 for tomography .Surgical treatment of SCC is followed by radiotherapy and chemotherapy. Early stages of SCC are treated by cholecystectomy and the late stages are treated by extensive hepatectomy including resection of segment 4 or 5 , 9.Survival rate following surgery is 20% in the early-stage patients and 10% in the late-stage patients .In this study, we present a 75-year-old female patient who presented to our emergency service with a pain in the right upper quadrant and underwent cholecystectomy due to acute cholecystitis and then presented with squamous cell carcinoma of the gallbladder in the pathological examination.A 75-year-old woman presented to our emergency service with a pain in the right upper quadrant, nausea, and vomiting. The patient had no clinical features and had no specific sign or symptom except for a temperature of 37.5°C and a positive Murphy's sign in the right upper quadrant.Biochemical parameters were as follows: BK: 12,000 , AST: 45 (0–35 U/L), ALT: 56 (0–35 U/L), and AMLZ: 120 (24–151 U/L). The other parameters were normal.Abdominal USG revealed swollen gallbladder with a wall thickness of 2 cm and echogenicity suggesting a 3 cm stone in Hartman's pouch. Depending on these signs, the patient was considered as having acute cholecystitis.The surgery started with laparoscopy. During the exploration, the gallbladder was swollen, the wall was thickened and inflamed, pericholecystic minimal fluid was detected, and the other intra-abdominal organs were normal. The gallbladder was suspended from the fundus. The Calot's triangle was dissected but it was difficult to dissect the Hartman's pouch since it was adhered to the cystic duct and to the 1 cm segment of the choledochus. We had no available conditions for frozen biopsy during the surgery.Afterwards, the procedure was converted to open surgery, and cholecystectomy was performed by the resection of 1 cm segment of the choledochus (because Hartman's pouch was not dissected since it was adhered to the cystic duct and had fibrotic adhesion). The choledochus was primarily anastomosed over the T-tube. The patient was uneventfully discharged on postoperative day 6. On postoperative day 14, a T-tube cholangiography was performed and no clinical problem was observed. The T-tube was removed on postoperative day 21.Pathological examination revealed the presence of (R0), T1 N0 M0 squamous cell carcinoma with clean resection borders and there was no tumor in five dissected lymph nodes Figures .No additional treatment was performed since the patient refused to undergo any treatment after surgery. The patient has been followed up for about two years and no clinical problem has been observed throughout the follow-up.Acute cholecystitis is the most common surgical problem of the gallbladder. Acute cholecystitis mainly results from gallstones and also may arise from a tumor which blocks the bile flow , 3.Acute cholecystitis with gallstones may overlap with gallbladder cancer. The incidence of this overlap is reported to be 2.3% . The femAcute cholecystitis presents no specific symptom suggestive of a tumor. Nevertheless, a palpable mass may be presented in the right upper quadrant at advanced ages –9.Acute cholecystitis generally presents nonspecific symptoms including a pain in the right upper quadrant, nausea, and vomiting and the diagnosis is often achieved by USG. Most common USG finding is wall thickening, which is detected in 70–100% of the cases. Further diagnosis of suspected cases is achieved by Computed Tomography (CT), Magnetic Resonance Imaging (MRI), Percutaneous Transhepatic Cholangiography (PTC), and Magnetic Resonance Cholangiopancreatography (MRCP). Similarly, our case presented with a pain in the right upper quadrant, nausea, and vomiting. However, no additional imaging techniques were performed since no clinical sign except for the wall thickening was detected and no suspected malignancy such as mass was detected on USG.The treatment of acute cholecystitis with gallstones is performed via two approaches: early stage and late stage (with antibiotic therapy). In our patient, we preferred the early-stage approach considering that the late-stage approach would worsen the general condition of the patient. Moreover, we preferred this approach since we had no gastroenterology department in our hospital that would perform the follow-up of the patient.Literature shows that if a tumor is detected in the gallbladder during the surgery, either the treatment should be continued and the definitive diagnosis should be achieved via frozen biopsy or the surgery should be terminated and the staging of the tumor should be performed . HoweverIn our patient, the Hartman's pouch was not dissected since it was adhered to the cystic duct and to the 1 cm segment of the choledochus. Nevertheless we could not understand whether this adhesion was a tumor or a fibrotic tumor and thus we performed cholecystectomy with a 1 cm resection of the choledochus and choledochocholedochostomy over the T-tube.Squamous cell carcinoma of the gallbladder has a poor prognosis since it is a rare condition and leads to delayed diagnosis , 3, 6, 8Radiotherapy and chemotherapy are suggested after the surgical treatment of SCC. However, our patient refused to undergo any of these treatments. Nevertheless, the patient has been followed up for about two years and no clinical problem has been observed throughout the follow-up.Gallbladder cancer, as in most cancers, is more common in advanced ages. Gallbladder cancer is more frequent in women than in men and it generally presents nonspecific symptoms such as acute cholecystitis –3, 7, 8.The laboratory findings of the patients with no suspicion of cancer present no findings other than the findings of acute cholecystitis –9. SimilA number of studies have shown that terminating the surgical procedure may be beneficial in the patients who are preoperatively suspected with gallbladder cancer and undergo biopsy . HoweverThe staging of gallbladder cancer is performed according to the Japanese Biliary Surgical Society system . Our patPrevious studies have shown that gallbladder cancer should be suspected in the advanced-age patients admitted to hospital with the symptoms of cholecystitis. However, the localization and diameter of the tumor are a key factor for the prognosis of the cancer , 8. The Squamous cell carcinoma of the gallbladder shows poor diagnosis, but since its overlap with cholecystitis presents early symptoms and thus leads to early diagnosis and effective treatment, the localization of the carcinoma is of prime importance , 8.Gallbladder cancer should be kept in mind in the advanced-age patients presenting with the symptoms of cholecystitis.