Low grade fibromyxoid sarcoma (LGFMS) is a distinctive variant of fibrosarcoma with a high metastasizing potential and sometimes long interval between tumour presentation and metastasis. We present the case of a 50-year-old male who developed a large mass in the posterior aspect of his lower left thigh. The tumor was excised with preservation of the neurovascular structures surrounded by the mass. The tumour measured 11 × 10 × 9 cm and on pathology evaluation was diagnosed as LGFMS. Due to the relative rarity of LGFMS, there is no dedicated protocol regarding follow-up recommendations. In order to early diagnose possible metastasis it is important to inform the patients about the longstanding metastatic potential of the disease. Low grade fibromyxoid sarcoma (LGFMS) is a distinctive variant of fibrosarcoma. According to Evans , who firAlthough it is a well-described entity it is speculated that many cases are not diagnosed as LGFMS, so it is still difficult to estimate its exact incidence. These tumours usually occur in the proximal extremities and trunk . SporadiHerein, we present the case of a 50-year-old male who developed a large LGFMS on the posterior aspect of his lower thigh. Imaging depiction, surgical approach of the mass, and current follow-up recommendations are discussed.A 50-year-old male presented with a large tumour on the posterior aspect of his lower left thigh. The mass was growing slowly during the past 3 years, but the patient did not seek for medical treatment until his presentation in our department. Physical examination revealed a firm mobile mass without tenderness, redness or warmth.Laboratory evaluation and plain radiographs were unremarkable. A computed tomography (CT) scan with intravenous administration of contrast material showed a large, heterogenous, low-density mass (Hounsfield units measuring between 15 and 50) surrounding the superficial femoral artery and vein within the Hunter's canal as well as the sciatic nerve at the lower thigh. A mixed density including hypodense and isodense components was evidence on CT. Magnetic resonance imaging (MRI) evaluation of the area also demonstrated a mixed myxoid and fibrous pattern within the tumour. The fibrous component was identified as hypointense areas on T1- and T2-weighted MR images and slightly enhancing on T1-weighted MR images after intravenous administration of gadolinium , as well as. One year later the patient is well with no evidence of disease.Low grade fibromyxoid sarcoma (LGFMS) is a distinctive variant of fibrosarcoma . It is cTen years after the first description of LGFMS by Evans , a similDifferential diagnosis of LGFMS includes lesions showing spindle cell proliferations with myxoid pattern with or without fibrous component . The entThe diagnosis of LGFMS or HSTGR is usually not difficult if the tumor has been removed completely and all the characteristic morphologic and immunophenotypic features described above are present. This is not usually feasible when the material derives from fine needle aspiration or needle core biopsy . In suchThe clinical presentation is usually long-standing and is mainly related to the anatomic location of the mass. LGFMS usually presents as a painless soft-tissue mass with a pre-biopsy duration of over 5 years in 15% of patients . In rareAlthough imaging findings of LGFMS are nonspecific, certain CT and MRI findings have been described ,19-21. OEvans  and GoodOnce the diagnosis of LGFMS or HSTGR is made, a full oncological assessment should follow. This should include a CT scan of the chest, since metastasis to the lung is the most common scenario. Because of the high risk of late metastasis, clinical follow-up and chest imaging should be performed for an extended period of time. However, it is still unclear how regularly imaging of the chest should be repeated .The case report presented herein, enriches the literature with information on imaging diagnosis and surgical treatment of this rare tumor. As there is no dedicated protocol regarding follow-up examinations and in order to early diagnose possible metastasis it is important to inform the patients about the longstanding metastatic potential of the disease.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.There are no competing interests; this is a basic academic research initiative.All authors contributed equally to this work. MGL, CA and MD participated in the design of the study and drafted the manuscript. IDG and AG participated in the design of the study. TAX and AB conceived of the study, and participated in its design and coordination and helped to draft the manuscriptMGL has had the main responsibility for the study and manuscript preparation. All authors read and approved the final manuscript.


A 53-year-old male presented with a giant cutaneous horn over the left leg. Cutaneous horn was excised and primary closure of the defect was done under spinal anesthesia. Histopathology showed underlying seborrheic keratosis. Cutaneous horn has been noticed on top of many clinical conditions of diverse etiology, such as actinic keratoses, wart, molluscum contagiosum, seborrheic keratoses, keratoacanthoma, basal cell and squamous cell carcinoma. We report a patient with giant cutaneous horn on the leg successfully treated by excision and wound closure. Cutaneous horn has been noticed on top of many clinical conditions like actinic keratosis, wart moluscum contagiosum, seborrheic keratoses, keratoacanthoma, basal cell carcinoma and squamous cell carcinoma. We report a case of giant cutaneous horn overlying a seborrheic keratosis treated with surgical excision and primary closure.A 53-year-old male presented with a horny projection on the left leg of 8 months duration. Initially, he had itchy hyperpigmented plaques on the leg of 4-year duration and the horny growth developed gradually over the plaque. There was no history of pain or discharge over the growth. On examination, there was a hyperkeratotic growth of 6 × 3 cm size  arising Cutaneous horns are elongated, keratinous projections from the skin, ranging in size from a few millimeters to many centimeters that resembles a miniature horn. The base of the horn may be flat, nodular or crateriform. The horn is composed of compacted keratin. The distribution of cutaneous horns usually is in sun-exposed areas, particularly the face, pinna, nose, forearms and dorsal hands. Usually, a cutaneous horn is several millimeters long. Malignancy is present in 16–20% of cases, with squamous cell carcinoma being the most common type.23Excision biopsy of the lesion and histopathological examination to rule out malignancy is recommended. Malignancies should be excised with appropriate margins and evaluated for metastasis. A careful physical examination of the lymph nodes draining the area of lesion often is adequate. Local destruction with cryosurgery is first-line treatment for verruca vulgaris, actinic keratosis and molluscum contagiosum.Treatment options include wide surgical excision with careful histological examination to exclude a focus of malignancy and carbon dioxide or Neodymium YAG laser is used for patients who refuse surgery.4


Cystic lesion of the omentum and mesentery are rare. The incidence of both cyst types has been variously reported to vary from 1/27,000-100,000 hospital admission. Omental cysts occur three to ten times less frequently than mesenteric cyst. Preoperative diagnosis is infrequently made because of lack of characteristic symptoms and signs.We present our diagnostic and management challenges in a 43-year-old man with an unusually giant omental cyst confirmed as fibrosarcoma at histology. The cyst gave the abdomen an anteroposterior diameter of about 74 cm that could not be penetrated sufficiently by X-ray photons to produce diagnostic image even at maximum attainable output. Patient benefited from surgical excision. The removed cyst contained about 35 litres of fluid.Neglected omental cysts as in this case may grow to enormous size, undergo malignant transformation and poses serious diagnostic and surgical challenges. Cystic lesion of the omentum, mesentery and retroperitoneum have been grouped together in the same category by several authors because they are similar embryologically and pathologically .Though the first reported mesenteric cyst was ascribed to Florentine anatomist Benevieni in 1507 , it was The incidence of both cyst types has been variously reported to vary from 1/27,000-100,000 hospital admission . A high We share our experience on the diagnostic and management challenges in an adult with an unusually giant omental cyst, found to be fibrosarcoma at histology in a resource poor environment.A 43-year-old man, a Nigerian of Yoruba ethnicity, presented with 6-year history of progressive abdominal swelling associated pain, weight loss and weakness on mild exertion. He had no facial or leg swelling, symptoms suggestive of impaired renal function, jaundice, vomiting and change in bowel habit.He admitted to a recent history of early satiety. He had attended five different hospitals and had various investigations and treatments at different times for what was thought to be ascites of chronic liver disease before presenting at our centre. The rapid increase in the abdominal swelling and the increasing difficulty/inability to lie or sleeps in the supine position without dyspnoea a month prior to presentation were of great concern to the patient.On examination, he was wasted, afebrile, anicteric, dyspnoeic and had finger-clubbing grade II but without other stigmata of chronic liver disease. He was well oriented, conscious and alert, and had globally intact cranial and motor functions.Abdomen showed massive non-mobile cystic distension  with posThe patient full blood count, liver function test, fasting blood sugar, Hepatitis B surface antigen (HBs Ag), urinalysis, PT and PTTK were normal. He has had Fine needle aspiration of the liver for cytology in one of his previous hospital visits and it was normal. Abdominal ultrasonography showed intra thoracic displaced normal sized liver with no focal intra-parenchymal lesion, bilateral hydroureteronephrosis worse on the right and a huge multiseptated cystic mass having some scattered mobile bright internal echoes (presumed to be haemorrhages) and irregular solid components. There was neither ascites nor lymphadenopathy. Sonographic impression of mesenteric cyst or omental cyst with suspected malignant transformation was made. Plain abdominal radiograph attempted could not penetrate the mass for diagnostic image even at maximum output attainable due to the size of this mass having an anteroposterior diameter of about 74 cm.Patient was planned for exploratory laparatomy but he defaulted to represent six months later in respiratory distress, whence he was cachetic, could no longer lay supine for a month, and anaemia had occurred (PCV = 22%.). Ultrasonographic findings this time was still similar to the former except for the increased and aggregating internal echoes presumed to be blood clots. Hence, an impression of haemorrhagic complex intra abdominal cyst  with probable malignant transformation was made.He had two pints of blood transfused and emergency exploratory laparatomy under general anaesthesia with endotracheal intubation. Findings at surgery were huge distended abdomen with dilated, tortuous vessels on the anterior abdominal wall and on the parietal peritoneum, huge omental cyst, containing about 35 litres of brownish fluid, and some solid components with areas of necrosis. The mass displaced the stomach and liver upwards, the transverse colon inferiorly, spleen laterally to the left and was adherent to the anterior abdominal wall. There was minimal ascites. He had complete excision of the cyst, which contained 35 litres of brownish fluid and weighed 37 kg .2 + Halothane, muscle paralysis with intravenous (IV) 100 mg suxamethonium for intubation then maintained with 6 mg bolus pancuronium followed by intermittent IV 2 mg pancuronium. Halothane was discontinued intraoperatively because of low blood pressure. Anaesthesia was reversed with IV 1.2 mg atrophine and IV 25 mg Neostigmine.Anaesthesia was maintained with 100% 0Intraoperatively patient had 10 litres of 0.9% (isotonic) Saline, 4 pints of blood and 10 mls of 10% calcium gluconate. Urine output was 500 mls over the 2 hours that surgery lasted. He was transferred to the intensive care unit (ICU) for monitoring and elective mechanical ventilation. While at the ICU, he had increasing abdominal distension that yielded frank blood on abdominal tap.He was re-explored and about 1.2 litres of free intra-peritoneal blood oozing from engorged parietal paritoneal vessels was evacuated. There was no area of active visceral bleeding seen. Haemostasis was secured with suture ligation of the oozing parietal peritoneum vessels, through and through apposition of the laxed anterior abdominal wall with sutures and application of abdominal pack and gauze on the anterior abdominal wall held with crepe bandage for tamponade effect. Further 8 litres of isotonic saline and 6 pints of fresh whole blood were given and intravenous calcium gluconate was repeated. Post-operative analgesics and antibiotics were commenced. Vital signs such as respiratory rate, pulse rate and blood pressure improved considerably within 6 hours. He was extubated 16 hours post re-exploratory surgery and continued on intranasal oxygen. By the second post-operative day, he was stable enough and he was commenced on oral intake. He was returned to the surgical ward on the third postoperative day.Histopathology of the removed specimen showed omental fibrosarcoma. Patient has been follow-up for 8 months and he remains well (see postoperative photograph 6 month later in The term mesenteric and omental cysts are merely descriptive topographic site and gross appearance These lesions though uncommon, elicit interest because of their unclear pathogenesis and confusing terminology .Mesenteric cysts have been estimated to be three to ten times more common than omental cysts . Howeveret al [According to Conzo et al , mesenteet al . ProbablMalignant change has been reported, but is uncommon. Hardin and Hardy  reportedOmental masses or cysts lack characteristic specific symptoms and signs. Hence, diagnoses are often not made untill the lesion has attained a size sufficient enough to be palpable or cause compression on organs or neighbouring structures. The diagnosis can therefore be challenging and a high index of suspicion is required .Omental cysts are usually differentiated from ascites by the fact that it is not associated with flanks bulging during recumbency since the cyst will follow as the patient moves. This feature could not be elicited in our patient because of the giant size of the mass at presentation.Though plain abdominal radiograph and upper gastrointestinal series could be helpful in making diagnosis, the imaging modality of choice is ultrasound . Plain aUltrasonography in this patient revealed multiseptated cyst having some solid components and features suggestive of internal haemorrhage. The extensive nature of this cyst hinders visualization of the pancreas. Thus, aside operator dependency, giant omental cyst may impose some ultrasonographic drawback. There were peculiar limitations to CT Scan in this patient ranging from non- ready availability, cost where available, the inability of this patient to lie in supine position without respiratory embarrassment, and above all the CT gantry will not admit the patient based on our previous experience with an abdominal mass that was not as giant as this case. We are aware that CT would have efficiently delineated this mass and its relationship to other intra abdominal structures .The goal of surgical therapy is complete excision of the mass, which sometimes may require inclusion of the adjacent structures . HoweverThe histological diagnosis showed omental fibrosarcoma. Primary malignancies of the omentum are rare events but they do occur . In our The diagnosis in this patient was very challenging in view of the limited resources. The patient responded well to surgical intervention though he had a turbulent immediate postoperative period.The management of this patient with giant omental cyst was challenging but the patient benefited from surgical excision though the immediate postoperative condition was turbulent. Histology of the removed specimen showed fibrosarcoma.


Diverse sequelae of central nervous system metastasis of choriocarcinoma have been reported, including infarction, intra or extra axial hemorrhages, aneurysm formation and carotid-cavernous fistula. Here we report a case of subdural hematoma as the first presentation of choriocarcinoma.The patient is a 34-year-old woman whose initial presentation of widely metastatic choriocarcinoma was an acute subdural hematoma, requiring decompressive craniectomy. Histopathologic examination of the tissue showed no evidence of choriocarcinoma, but the patient was found to have diffuse metastatic disease and cerebrospinal fluid indices highly suggestive of intracranial metastasis.Choriocarcinoma frequently metastasizes intracranially. We review the diverse possible manifestations of this process. In addition, the cerebrospinal fluid:serum beta-human chorionic gonadotropin ratio is an important factor in diagnosing these cases. Finally, the role of the neurosurgeon is discussed. Choriocarcinoma is a rare gestational trophoblastic disease that complicates approximately 1 in 50,000 term pregnancies and 1 in 30 hydatidiform moles. PrognosThe patient is a 34-year-old woman who had an acute episode of excruciating headache and was later found obtunded. She had a history of a normal pregnancy three years prior to presentation. She then had an abnormal pregnancy requiring dilation and evacuation at 10–12 weeks that was found to be a molar pregnancy. She became pregnant again 9 months after the dilation and evacuation of the molar pregnancy. This ended in a spontaneous, uncomplicated delivery 5 months prior to her presentation. There was no history of trauma, recent or remote.Upon arrival to Emergency Department, she had fixed, dilated pupils and displayed extensor posturing. Computerized tomography of the head without contrast Figure  showed aExamination of the tissue showed no evidence of vascular malformation or neoplasm, and cytokeratin immunolabeling showed no signs of choriocarcinoma.Following neurological and hemodynamic stabilization, CT angiogram showed no evidence of aneurysm or vascular pathology. Magnetic resonance imaging Figure  showed cApproximately one half of tumor-related hemorrhages are the first manifestation of the tumor. In addition, there are numerous reports in the literature of other presentations, including intracranial hemorrhage, subaracet al. reported a patient who presented with a subdural hematoma due to ruptured aneurysm of the angular artery following surgical resection of a choriocarcinoma in the left adnexa[Here we report a case of choriocarcinoma presenting as subdural hematoma. This has been reported only twice before in the literature. In 1986, Toyama ft adnexa. The patIn the female patient of reproductive age, choriocarcinoma must be considered in the differential for any intracranial hemorrhage. A lesion may be apparent on CT scan, but often there is no lesion visible apart from the hemorrhage. Suresh reports a series of 10 hemorrhages from confirmed cases of choriocarcinoma in which only two had visible lesions on CT. The keyImportantly, CNS metastases are very responsive to chemotherapy. There are reports of complete resolution of CNS disease including intracranial metastases, neoplastic pseudoaneurysms, and neoplastic fistulas with chemotherapy alone -7. GivenChoriocarcinoma is a relatively uncommon malignancy associated with pregnancy. The disease may initially present with intracranial hemorrhage or other CNS manifestation in a significant proportion of patients. It is therefore critical to have a high level of suspicion regarding choriocarcinoma in any patient of reproductive age or with a history of abnormal pregnancy who presents with intracranial pathology. In the case of hemorrhage, it is essential to send the evacuated hematoma for histopathological examination. Increased beta-HCG levels can aid in the diagnosis, and a low serum:CSF beta-HCG level can be strongly suggestive of intracranial choriocarcinoma even in the absence of histopathologically proven disease.Written informed consent was obtained from the family of the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.BGR assembled clinical data and drafted the manuscript, MKB was the primary surgeon and reviewed and revised the manuscript. Both authors read and approved the final manuscript.


Desmoid tumors are rare, benign fibroblastic tumors that are locally infiltrative and can cause extensive morbidity by destruction of adjacent vital structures. Due to the rarity of these tumors, evidence regarding optimal treatment protocols is drawn from case reports and single-arm series with small patient numbers. We report a case of a patient with a desmoid tumor of the left supraclavicular region that was diagnosed and treated in our department and a review of the current literature. The fibromatoses or desmoid tumors are a group of rare disorders arising from the connective tissue of the muscle, the overlying fascia or aponeurosis . Althougth postoperative day. During his follow-up MRI study, 6 months after his operation, no evidence of tumor recurrence were detected.A 21-year-old Caucasian Greek male with no past medical history, presented with an enlargement in his left supraclavicular region associated with numbness in his left arm during physical activity. Upon physical examination, there was a smooth, firm, non-tender supraclavicular mass and no palpable lymph nodes. Neurological examination of the upper extremities did not show any sensory or motor deficits. Magnetic resonance imaging (MRI) of the neck revealed an enhancing mass in the posterior cervical triangle, extending to the thoracic cavity  as well as cytotoxic and noncytotoxic chemotherapy. Given the benign nature of these tumors, treatment strategies aim at achieving local control while preserving proper function and providing with an adequate cosmetic result . When meIn summary, desmoid tumors are rare and benign neoplasms with a unique biologic behavior. Treatment strategies must be individualized so as to provide adequate local control with subsequent acceptable functional and esthetic outcome. Despite the applied therapeutic method, due to the high recurrence rate, these patients must be closely followed by clinical examination and radiographic studies.MRI: Magnetic resonance imaging; RT: Radiation therapy.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.All authors contributed equally to this work. KI and KG, performed the surgery, PA and TS performed the pathological examination of the excised specimen, KK, CJ and KN reviewed the current literature. KG, EL and AM contributed in writing and revising the manuscript. All authors read and approved the final manuscript.


Osteoid osteoma is a benign osteoblastic tumor usually seen in adolescent and young males. In the paediatric age group, since the history may be difficult to elicit, there are often problems in early diagnosis. The author reports an unusual presentation of osteoid osteoma in a ten-year-old girl, which could not be diagnosed by conventional X-rays and CT scan. Osteoid osteoma first described by Jaffe 1n 1935, is a benign osteoblastic tumour, mostly seen in adolescent and young males. Tumors A ten-year-old girl was seen in the orthopedic clinic with recurrent episodes of pain left ankle of around five months duration. She was not having diurnal variation of her symptoms and her medical history was unremarkable. There was a small tender swelling over the posteromedial aspect of the left ankle between the postero medial border of tibia and the tibialis posterior tendon. Movements of the ankle joint were free. Her blood parameters were normal.Routine X-ray of the left ankle showed a ballooned out lesion over the posterior aspect of the left tibia close to the growth plate, with a thin outer shell. There was no sclerosis around the lesion and no calcification could be seen inside. Ultrasound scan of the lesion didn't reveal any gross abnormality (see Figure A CT scan was done which showed an elliptical hypodense area in the posterior distal tibia with only minimal sclerosis. There was no soft tissue component and periosteal reaction. The radiological diagnosis was fibrous cortical defect (see Figure The patient was advised surgery as she was symptomatic. Through a postero medial incision the lesion was approached after retracting the tibialis posterior tendon and the neuro-vascular bundle. Ballooning of the distal posterior tibia was found, which was curetted. Punctuate bleeding tissue was removed with high speed burr. Histopathology report was consistent with osteoid osteoma. The patient was asymptomatic at one year follow up.Clinical symptoms and radiological findings are enough to make the diagnosis of osteoid osteoma at presentation. The location of the osteoid osteoma may be intra cortical, subperiosteal, endosteal, or medullary. The lesion is most commonly located in the cortex of the long bones with dense reactive sclerosis. Presence of area of sclerosis around the lucent area, due to reactive bone formation is typical of osteoid osteoma. The nidRadiographic appearance may vary with location of the tumor. The tumRadiographs in nondiaphyseal osteoid osteomas may be misleading and the tumor may be missed in most of the cases. In a small series by Davidson et al there was a delay of six months in making the diagnosis because of the atypical radiographic appearance. The delContrary to this Kayser believesOsteoid osteoma tends to regress over a period of time even without treatment. Salicylates can accelerate healing in osteoid osteoma and is a good diagnostic and therapeutic consideration. The staSubperiosteal osteoid osteomas produce atypical radiographic picture and the radiological features may be misleading. Subperiosteal osteoid osteoma is a rare lesion with atypical radiographic features. Our case was also not diagnosed as osteoid osteoma as the location of the tumor was atypical, and there was no reactive new bone formation.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journalThe authors declare that they have no competing interests.SSS was responsible for diagnosis and management of the case, analysis of data, preparation of manuscript .VR was responsible for management of the case, analysis of data and preparation of manuscript.


Computed tomography is considered as the imaging modality of choice in the diagnosis of genitourinary tuberculosis, while magnetic resonance imaging may provide some informative features corresponding to the pathologic stage of the disease. We herein present a case report where magnetic resonance imaging showed the informative features, and a clue to further examinations in focusing on renal tuberculosis. A 53-year-old Japanese woman was referred to our institution for recurrent cystitis. Abdominal sonogram was initially performed, revealing the presence of a left upper pole cystic lesion in a hydronephrotic kidney and dilatation of the ipsilateral ureter. Subsequent CT examination, including both plain and contrast-enhanced images confirmed the presence of a cystic mass at upper pole of the left kidney, accompanied by thinning and enhancement of the renal parenchyma. The dimensions of the lesion were 40 × 25 mm. No renal calcifications were noted. Left ureteral dilatation was also seen, with thickening and enhancement of the ureteral wall . Based oThe genitourinary tract is one of the most common sites of extrapulmonary tuberculosis, accounting for 15-20% of infections outside lungs and approximately 4-8% with pulmonary tuberculosis will develop significant genitourinary tuberculosis ,4. CT is


Desmoid fibromatoses are benign, slow growing fibroblastic neoplasms, arising from musculoaponeurotic stromal elements. Desmoids are characterized by local invasion, with a high rate of local recurrence and a tendency to destroy adjacent structures and organs. Desmoid fibromatoses are rare in children, and though they may occur in the head and neck region, are extremely rare in the paranasal sinuses. Here we report a case of extraabdominal desmoid fibromatosis in a seven-year-old boy involving the sphenoid sinus, one of only six published reports of desmoid fibromatosis of the paranasal sinuses. The expansile soft tissue mass eroded the walls of the sphenoid sinus as well as the posterior ethmoid air cells extending cephalad through the base of the skull. We discuss the clinicopathologic features of this lesion, including structural and ultrastructural characteristics, and we review the literature regarding treatment and outcome. Desmoid tumors arise from musculoaponeurotic stromal elements and are locally invasive, deep-seated fibrotic tumors. They are destructive of surrounding tissue, with a high rate of recurrence, but are not known to have the capacity to metastasize. Desmoid tumors have two general classifications, intraabdominal and extraabdominal. This distinction is significant in determining proper clinical management. Extraabdominal tumors are predominantly sporadic, and often can be effectively treated with local resection; systemic treatment is generally reserved for refractory tumors. Conversely, intraabdominal desmoid fibromatosis, for example those seen with familial adenomatous polyposis and Gardner syndrome, are often diffusely infiltrative and surgically unresectable; systemic therapy is considered first-line treatment of intraabdominal desmoids. Extraabdominal tumors in the paranasal sinus are extremely rare; to the best of our knowledge only six cases have been reported in the literature -6 Table.An otherwise healthy seven-year-old male presented with a six month history of chronic sinus congestion and halitosis. He was initially treated for atopy and bacterial sinusitis with no resolution of symptoms. Suspicion was raised of a foreign body in the nose and ENT consultation was ordered. Prior to endoscopic removal of the foreign body, computed tomography (CT) of the head was performed.CT revealed a large expansile mass, 4 cm in greatest dimension, expanding and eroding the walls of the sphenoid sinus and the posterior ethmoid air cells. Because the mass extended cephalad into the base of the skull, magnetic resonance imaging (MRI) was performed. MRI found no evidence of meningeal involvement or brain parenchymal invasion and the major intracranial arteries appeared intact. The right optic nerve was displaced but without evidence of impingement.The patient underwent functional endoscopic sinus surgery with biopsy of the lesion. Histological analysis revealed a cellular myofibroblastic neoplasm suggestive of extraabdominal desmoid fibromatosis Figures , 2. SurgDesmoid tumors are rare, accounting for approximately 0.03% of all neoplasms, and less than 3% of all soft tissue tumors. The estimated incidence in the general population is 2-4/1,000,000/year, which in the US translates to approximately 900 new tumors annually . IndividBecause of their locally infiltrative nature, desmoid tumors are traditionally treated by local resection with wide surgical margins when significant morbidity can be avoided ,16. ConsIn patients for whom surgery is not an option, primary RT is an effective alternative therapeutic course. In several reports, RT alone (50 to 60 Gy) or combined with surgery in patients with positive resection margins achieves long-term control in approximately 70% to 80% of patients with desmoids ,27,29-31Patients with extraabdominal desmoids and multiple locoregional recurrences despite adequate surgical and/or radiation treatment are generally considered for systemic therapy. Other indications for systemic therapy include unresectable tumors and intraabdominal desmoids. In these settings, early and aggressive systemic therapy is important to avoid life-threatening complications. A variety of agents are active, including noncytotoxic therapy , hormone manipulation, and pirfenidone) and cytotoxic chemotherapy. The conclusions that can be drawn as to the relative effectiveness of these agents in the treatment of desmoid tumors are limited by the low incidence. Unfortunately the majority of data generated on this topic consists of case reports. Therefore, in the absence of clear evidence, a conservative approach is appropriate. In cases where there is no impending threat to life or function it is reasonable to begin with less toxic approaches, such as hormone therapy or NSAIDs. Cytotoxic chemotherapy is a more appropriate choice for patients with rapidly growing tumors or those who are highly symptomatic.Clinical and experimental evidence suggest the hormone dependency of desmoid growth. Clinical benefit is reported in nearly 50% of patients with tamoxifen treatment, with most of the objective responses being partial rather than complete. Tumors are slow to manifest an actual reduction in size, and not infrequently, shrinkage lags behind discontinuation of therapy by months or even years. Response durations vary to a great degree, ranging from seven months to 12 years . The mecAlthough desmoid tumors as a group are generally slow growing with low metastatic potential, there are several highly active chemotherapy regimens that can potentially produce durable response. The combination of low dose methotrexate and vinblastine has shown promising results, particularly in children -52. One Desmoid fibromatosis are rare pediatric tumors, and the case reported here is one of only six published accounts of pediatric desmoid fibromatosis of the paranasal sinuses. Aggressive juvenile fibromatoses are a group of lesions with variable response to treatment; they are locally aggressive but have low metastatic potential. Current treatment ranges from traditional surgical resection to multidisciplinary approaches involving local radiation and/or systemic cytotoxic and cytostatic agents. However, surgical resection with wide margins remains the primary treatment for extraabdominal fibromatoses. Reports in the literature are conflicting as to the importance of obtaining tumor-free surgical margins; some retrospective analyses have found a significant decrease in recurrence rate with negative margins, while others have not. Based on these reports, the optimal treatment strategy for pediatric desmoids fibromatoses is patient-dependent, and clinical decisions must be made based upon tumor location, risk of surgical morbidity and risk of radiation-induced damage. Radiation therapy and cytotoxic chemotherapy in pediatric patients should be used in cases that are refractory to surgery and noncytotoxic systemic therapy due to the potential of growth disturbance, contracture, and the development of secondary malignancy.CT: computed tomography; IFN-alpha: interferon alpha; MRI: magnetic resonance imaging; NSAID: non-steroidal anti-inflammatory drug; PDGFRA: platelet-derived growth factor receptor-alpha; RT: radiation therapy; SMA: smooth-muscle actin.The authors declare that they have no competing interests.SL, RE, and LH secured the case, conducted the literature review, and participated in the preparation of the manuscript. All authors read and approved the final manuscript.Written informed consent was obtained from the patient's parents for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Histopathology was suggestive of ganglioneuroma positive for ACTH immunostaining.We present a case of an eight-year-old female presenting with four months history of progressive weight gain, short stature, obesity, mild acanthosis, moon facies and buffalo hump. Biochemically, low-dose and high-dose Dexamethasone tests were not suppressible, ACTH was raised and 24h urinary metanephrines were normal. The CECT scan showed a 3cm paraganglioma. Tumor was excised via 11 Association of Cushing's syndrome with ganglioneuroma is very rare. Ganglioneuromas may be hormonally active. Hypertension, diarrhea, flushing and virilization may occur as a result of the secretion of catecholamines, vasoactive intestinal polypeptide or androgenic hormones. This case is presented due to its extreme rarity.An eight-year-old female  presenteThe CT scan abdomen  showed ath rib transcostal retroperitoneal approach a 6 × 4 cm tumor [Through 11cm tumor  at the lcm tumor . PostopeGrossly this grayish white nodular mass was homogeneous on cut section. Microscopically tumor was encapsulated showing proliferation of spindle Schwannian cells in short fascicles. Ganglion cells were conspicuous in between, scattered in small aggregates . SpherulTwo lymph nodes included showed mild reactive changes with no evidence of metastases.Final diagnosis was an ectopic ACTH-secreting para aortic ganglioneuroma Stage 1[Follow-up period was six months. Clinically, the patient lost 6kg in weight, showed improvement in her daily performance. Biochemically, serum ACTH and cortisol levels were normal at the end of one month post op. Patient is off the antihypertensives. Monthly follow-up during the first postoperative year was planned to detect early recurrence if any.Ganglioneuromas originate from neural crest sympathogonia (undifferentiated cells of the sympathetic nervous system). Neuroblastomas, ganglioneuromas and ganglioneuroblastomas are collectively known as neuroblastic tumors.These tumors may show hormonal activity. Hypertension, diarrhea, flushing and virilization may occur as a result of the secretion of catecholamines, vasoactive intestinal polypeptide or androgenic hormone. Though tMost frequently these tumors occur in the abdomen. Common locations include the adrenal gland, paraspinal retroperitoneum (sympathetic ganglia), posterior mediastinum, head and neck. Locations such as the urinary bladder, bowel wall, abdominal wall and gallbladder were considered unusual.Ganglioneuromas are rare, benign, fully differentiated tumors that contain mature Schwann cells, ganglion cells, fibrous tissue and nerve fibers. These tuGanglioneuromas are staged using the INSS . TreatmenCushing's syndrome due to ectopic ACTH production poses diagnostic challenges by mimicking the pituitary-dependent form of Cushing's syndrome. Ectopic ACTH syndrome has a slight female predominance. Bronchial carcinoid, Islet cell cancer, Small cell carcinoma lung, medullary thyroid carcinoma were among the common etiologies.5The first case report of ectopic ACTH syndrome induced by an extra adrenal abdominal paraganglioma (pheochromocytoma) has been reported in 2005. The pres


Benign cervical goiters rarely cause acute airway obstruction.We report the case of a 64-year-old woman of African descent who presented with acute shortness of breath. She required immediate intubation and later a total thyroidectomy for a benign cervical multi-nodular goiter with no retrosternal tracheal compression.Benign multi-nodular goiters are commonly left untreated once euthyroid. Peak inspiratory flow rates should be measured via spirometry in all goiters to assess the degree of tracheal compression. Once tracheal compression is identified, an elective total thyroidectomy should be performed to prevent morbidity and mortality from acute airway obstruction. Benign multi-nodular goiter is a common problem affecting 5% of the general population in non-endemic and 15% . RetrostA 64-year-old hypertensive woman of African descent presented to our emergency room with a two-day history of worsening shortness of breath and stridor. She had been aware of a recurrent goiter for over 15 years, having had a partial thyroidectomy 35 years ago for benign multi-nodular disease. Over the past year, she had been experiencing shortness of breath on exertion, generally relieved by rest. However, the period of rest needed to relieve her dyspnea had been increasing in duration. She did not have any hyperthyroid or hypothyroid symptoms and there was no history of fever, dysphagia, pain or hoarseness.2) was 78% on room air. A large multi-nodular goiter was obvious: right lobe 14×11 cm, left lobe 11×8 cm , tachycardia (120 beats/minute) and blood pressure of 160/95 mmHg. Her pulse oximeter oxygen saturation  level of 1.4 mIU/L and free T4 level of 1.5 μg/dL. A computed tomography (CT) scan of the neck and thorax showed gross enlargement of both lobes of the thyroid with multiple nodules of varying sizes. There was marked narrowing of the cervical trachea with only the ET maintaining the patency of the airway (Figure After intubation, she stabilized and was able to breathe comfortably with the ET y Figure . The resA total thyroidectomy was performed on the fourth day after admission. The gland was dissected easily with preservation of the recurrent laryngeal nerves and parathyroids. A tracheostomy was placed prophylactically. The trachea was normal with no features of tracheomalacia. She returned to our intensive care unit and recovered with no complications. Her calcium levels did not decline post-operatively. The tracheostomy was removed on day 10 post-operatively. Histology tests confirmed a benign multi-nodular goiter.Acute airway obstruction has been described extensively for retrosternal benign goiters and thyroid malignancies. Benign cervical goiters causing acute airway obstruction are rare. Reports have been published suggesting acute obstruction to be due to sudden hemorrhage into a cyst, an upper respiratory tract infection causing edema, tracheal collapse or worsening of a medical illness ,6-9. In et al. [Jauregui et al.  suggesteet al. . If specet al. . Compromet al. -8. Peak et al. . Using sIn our patient, spirometry could have identified our patient's compromised respiration but life-saving, urgent intubation was essential. She developed stridor and worsening dyspnea over a two-day period suggesting progressive compromise of the tracheal lumen. In spite of the goiter's large size, no structural tracheal defect was evident at intubation or surgery. This suggests purely mechanical compression of the trachea by the huge goiter within the firm, unyielding cervical fascia, causing her upper airway obstruction.Her symptoms had been worsening over a year-long period. The slow growth rate of the thyroid gland allows adaptation to extrinsic hypoventilation without acute symptoms . TherefoBenign euthyroid multi-nodular goiters are common. The incidence of acute airway obstruction due to a benign goiter, however, is quite low, with cases due to purely cervical goiters being rare. This has allowed physicians a conservative approach to management. On review of the literature, however, tracheal compression with decreased inspiratory flow rates are found in one-third of cases. The management of benign cervical multi-nodular goiters should include inspiratory spirometry. Once compromised airflow is identified, prophylactic total thyroidectomy should be performed to avoid the dangers of complete airway obstruction.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.ST and AS provided medical assistance to the case and VN provided surgical findings. AS and VN performed the literature search and major contributors to writing the manuscript. ST and VN edited the manuscript. All authors have read and approved the final manuscript.


Intussusception in pregnancy is rare and poses unique diagnostic and therapeutic challenges. We present the case of a 22 year old, 20 weeks pregnant woman who presented with acute abdominal pain. Following abdominal ultrasound scanning she was diagnosed with intussusception. The patient underwent laparotomy and a small bowel resection was performed without any post operative complications. We review the literature to give a concise and up to date summary on the diagnosis and treatment of the condition with particular emphasis on the recently recognised usefulness of ultrasound scanning. Intussusception is a rare but potentially life threatening (mother and child) complication in pregnancy challenging both gynaecologists and surgeons. Its diagnosis is difficult and emergency surgery indicated.A 20 weeks pregnant, 22-year-old nulliparous white woman of Polish origin was admitted through our accident and emergency department with acute onset of severe cramp like lower abdominal pain. Her pulse rate and blood pressure where normal. The initial abdominal examination was unremarkable and baseline blood tests, apart from a potassium of 2.9, where within normal limits. She was admitted by the gynaecological team for observation and an urgent pelvic ultrasound scan was performed. This did not show any pathology. The foetus was healthy. Later the same evening the patient was re-examined and a mobile mass was detected in the left upper quadrant of her abdomen. Our surgical team was contacted and we reviewed her the same night. At the time she was still in pain but had improved somewhat. Once again the mobile mass was palpable. Unsure of the diagnosis we organised an abdominal ultrasound scan for first thing in the morning. This showed features suggestive of intussusception .Following discussion with the patient and the radiological and gynaecological consultants emergency surgery was performed. This showed a necrosed entero-enteric intussusception starting at the duodeno-jejunal flexure. We performed a small bowel resection with anastomosis of the small bowel to the 4th part of the duodenum. The total length of small bowel removed was 126 cm. Postoperative recovery was uneventful for mother and child and the patient was discharged 8 days after admission. There where no problems on follow up. Histology showed a benign polyp as leading lesion.Intussusception is a rare but serious complication in pregnancy necessitating emergency surgery. Even though the patient is usually admitted under the care of the gynaecological team it is normally the surgeon who is asked to assist with the diagnosis and ultimately to operate. Intussusception is most common in childhood accounting for 15% of bowel obstructions . Its incThe treatment of intussusception in the adult is almost always surgery -4. IntusIntussusception in pregnancy is rare. Intestinal obstruction in pregnancy has been reported to occur with an incidence between 1:2500-3500, most commonly secondary to adhesions or gastrointestinal volvolus . IntestiEven though it is a rare occurrence, surgeons should be aware of the possibility of intussusception in pregnancy - it needs urgent and decisive intervention. Ultrasound scanning is a safe investigation in pregnancy and frequently confirms the diagnosis.


Gallbladder adenomyomatosis is an epithelial proliferation and hypertrophy of the muscularis mucosae of the gallbladder. Rokitansky-Aschoff sinuses are a characteristic of this condition. The segmental adenomyomatosis has a higher risk of developing into gallbladder carcinoma, especially in the fundal region of elderly patients.We report the case of a patient affected by chronic calculous cholecystitis with diffuse adenomyomatosis associated with dysplastic adenoma.An 81-year-old woman presented at our hospital with a 1-year history of intermittent pain localized at the right upper abdominal quadrant, without diffusion to any other body part. On physical examination the abdomen was soft, not distended, and tender to palpation in the right upper quadrant. Murphy sign was negative. Laboratory tests were normal. The patient was scheduled for a laparoscopic cholecystectomy, and neither endoscopic ultrasonographic scan nor magnetic resonance imaging was performed. The operation, performed after obtaining informed consent, was uncomplicated and the intra-operative pathological examination showed no malignancy. The definitive pathological examination of the gallbladder showed: multiple stones of cholesterol origin; diffuse mucosal adenomyomatosis; and a 1.1 cm pedunculated mass localized at the fundus, whose surface was lumpy. This mass was diagnosed as an adenoma with multiple areas of severe dysplasia.The adenoma of the gallbladder, together with the dysplasia, represents a biological carcinogenetic model. Carcinoma has rarely been reported in adenomyomatosis. Degenerative risk suggests surgery should be mandatory when there is a concomitant presence of large adenoma and adenomyomatosis. Gallbladder adenomyomatosis (GBA) is defined as an epithelial proliferation and hypertrophy of the muscularis mucosae of the gallbladder with outpouching of the mucosa into or through the thickened muscular layer, forming the so called Rokitansky-Aschoff sinuses, which are a characteristic of this condition . GallblaSegmental adenomyomatosis has a higher risk of developing into gallbladder carcinoma, especially in the fundal region of elderly patients . ChronicAn 81-year-old woman presented at our hospital with a 1-year history of intermittent pain localized at the right upper abdominal quadrant, without diffusion to any other body part. The patient denied episodes of fever during the previous months. Her medical history was significant for hypertension, transient ischemic attack (TIA), and sigmoid diverticulitis.The patient was alert and oriented during physical examination. The abdomen was soft, not distended, and tender to palpation in the right upper quadrant. Murphy sign was negative.Laboratory tests were normal. Ultrasonographic scan (US) of the right upper abdominal quadrant showed multiple gallstones. A heterogeneous, hypoechogenic pedunculated mass, 1.1 cm in diameter, was found in the fundus of the gallbladder. The patient underwent an upper gastrointestinal endoscopy (UGIE) that showed normal gastro-duodenal mucosa. Colonoscopy showed a small polyp, which was removed. The patient was scheduled for a laparoscopic cholecystectomy. Endoscopic US and magnetic resonance imaging (MRI) were not performed. The operation was uncomplicated and the intra-operative pathological examination showed no malignancy. The postoperative course was unremarkable and the patient was discharged on the first postoperative day.The definitive pathological examination of the gallbladder showed: multiple stones of cholesterol origin; diffuse mucosal adenomyomatosis Figure ; and a 1Polyps of the gallbladder can be differentiated into non-neoplastic and neoplastic lesions . They caTumoral polyps may be classified as adenomas and adenocarcinomas. Sixty percent of gallbladder adenomas are associated with cholecystolithiasis . There iAdenomyomatosis is an acquired, benign proliferative lesion of the gallbladder characterized by mucosal proliferation with invaginations and diverticula penetrating into the thickened muscular layer (Rokitansky-Aschoff sinuses) . AdenomyIn our patient, we found an adenoma with signs of severe dysplasia inside areas of diffuse adenomyomatosis. This has not been reported and could represent a different risk for carcinogenesis. Chronic calculous cholecystitis with dysplastic adenoma associated with diffuse adenomyomatosis is not found in literature, and its discovery may be due to laparoscopic cholecystectomy, which has been increasingly used in the last two decades.Patients with adenomyomatosis and (or without) adenomas may present signs or symptoms of chronic cholecystitis or acute-on-chronic cholecystitis such as right upper quadrant pain, nausea, vomiting associated with meals, or more unexplained signs . HoweverUS is useful to diagnose adenoma and adenomyomatosis, and could be sufficient in patients that should be treated surgically for symptoms or for the dimensions of adenomas (>1 cm in diameter). In asymptomatic patients with lesion smaller than 1 cm, MRI or ecoendoscopic ultrasonography (EUS) may be used to obtain a differential diagnosis . EUS mayOur patient only underwent US due to her symptoms, and was promptly operated on. Surgery should be performed quickly when symptoms are present. In asymptomatic patients, laparoscopic surgery may become mandatory if diagnosis remains uncertain after EUS or MRI. Moreover, as in this case report, degenerative risk may exist in non-reported conditions, suggesting surgery should be mandatory when there is a concomitant presence of large adenoma and adenomyomatosis.GBA: gallbladder adenomyomatosis; TIA: transient ischemic attack; US: ultrasonographic scan; UGIE: upper gastrointestinal endoscopy; MRI: magnetic resonance imaging; EUS: ecoendoscopic ultrasonography.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.IDC: designed the research, carried out the study, drafted the manuscript, and also performed the operations. AT: contributed to this work by writing the paper and performing the literature research. EP: contributed to this work by writing the paper and performing the literature research. MZ: performing the literature research. AG: performed the pathologic study. All Authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/10/41/prepub


Atrial myxomas are the most common primary cardiac tumors. They are usually small or moderate in size by the time of the diagnosis, exhibiting non specific cardiac or systemic symptoms, and are most frequently soft and friable without microscopic signs of ossification. We describe herein an extremely rare case of an asymptomatic giant left atrial myxoma with angiographic neovascularization and ossification.An asymptomatic 58-year-old male with a giant left atrial tumor, was transferred to our Unit for surgical treatment. The tumor was an incidental finding during a work-up for hemoptysis due to bronchectasis. The coronary angiogram showed tumor vessels originating from the RCA. The tumor macroscopically did not resemble a myxoma, considering its dimensions (12 × 10 cm) and its solid substance. The mass was excised together with the interatrial septum and the right lateral LA wall close to the right pulmonary veins orifices. The defect was closed with Dacron patches in order to prevent malformation of both atria. The pathology study revealed a benign myxoma with excessive osteoid (mature bone) content.We consider our case as extremely rare because of the asymptomatic course despite the large size of the tumor, the blood supply from the right coronary artery and the bone formation. Atrial myxomas are the most common primary cardiac tumors. They are usually small or moderate in size by the time of the diagnosis, exhibiting non specific cardiac or systemic symptoms, and are most frequently soft and friable without microscopic signs of ossification. We describe herein an extremely rare case of an asymptomatic giant left atrial myxoma with angiographic neovascularisation and mature bone elements.th postoperative day in sinus rhythm and remains well and asymptomatic two years after surgery.A 58-year-old male was referred for evaluation of a calcified left atrial mass that was found in a thoracic CT scan performed during the course of haemoptysis investigation and was attributed to lung bronchiectasis after pulmonary work-up. Patient's past medical history was unremarkable. Further evaluation with transesophageal echocardiography revealed a sessile lesion measuring 10 × 12 cm in diameter arising from the interatrial septum in an otherwise normal-sized left atrium. Coronary angiography followed showing well organized tumor vessels arising from the right coronary artery fig. . The patAtrial myxomas are benign slow growing neoplasms that arise from the interatrial septum and extend into the left or right atrium. Usually they are associated with atypical symptoms and only a 4% remain completely asymptomatic . ClinicaCoronary angiography a useful diagnostic tool for evaluating tumor vascularity and rule out concomitant coronary artery disease should be performed in all patients over 40 years of age. Neovascularization has been reported up to 80% of myxoma cases . MoreoveWe consider our case as extremely rare because of the asymptomatic course despite the large size of the tumor, the blood supply from the right coronary artery and the bone formation.The authors declare that they have no competing interests.All authors have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data and have been involved in drafting the manuscript or revising it critically for important intellectual content. All authors read and approved the final manuscript.MP: Manuscript Preparation, Literature Search, Study Design.NP: Manuscript Preparation, Literature Search.PR: Histo-pathologic diagnosis, Data Interpretation, Literature Search.LK: Histo-pathologic diagnosis, Data Interpretation, Literature Search.EK: Manuscript Preparation, Literature Search.


Primary sternal malignant fibrous histiyocytoma (MFH) is highly rare. Effective treatment modality is surgical resection with wide margins. However, to date, the effects of radiotherapy or chemotherapy has not been clearly defined.Herein, we aimed to present a 50-year old female patient with MFH occurred in the radiotherapy field who had had surgical procedure for breast cancer 19 years ago and had followed by radiotherapy. Neoadjuvant chemotherapy was applied for MFH due to cardiac and mediastinal vascular invasion. Wide resection was carried out for the mass after having been decreased in size following neoadjuvant chemotherapy.Neoadjuvant chemotherapy was an effective method. In planning the surgical resection, the size of the tumor before chemotherapy should be considered as the initial size and surgical margins should be determined accordingly. Primary sternum tumors are rare entities, almost all of which have a malignant progression . ChondroA 50-year-old female patient applied with ulcerated and painful lesion on the sternum Figure . The pat2 (3 days), mesna 2500 mg/m2 (3 days), and adriablastina 50 mg/m2 (1 day) (IMA) was started with 21-day intervals. After two cures of chemotherapy, the size of the lesion was 3 × 3 cm. Repeated thorax CT showed regression of the local invasion, and the tumor was operable. Thus, operation was planned.The patient did not have any findings of distant metastasis, but was considered inoperable because of local invasion. A chemotherapy protocol of iphosphamid 2500 mg/mIntraoperatively, the lesion on the corpus stern was totally excised with a 4-cm margin along with the health tissue. The manubrium sterni was preserved. To provide stabilization, prolene mesh and methyl methacrylate were used. Then, the areolar fatty tissue and skin composite transposition flap was formed and transpositioned on the prolene mesh. A drain with negative pressure was placed under the transposition flap. The remaining right breast tissue was advanced along the inframammarian sulcus and the flap donor area was closed.The histopathological evaluation of the incisional biopsy material showed a tumor growth of mesenchymal character with cellular appearance. The tumor consisted of cells with spindle character forming non-marked storiform pattern at certain places and fewer polygonal cells. There were marked nuclear pleomorphism and common mitosis. Atypical mitoses and tumor giant cells with bizarre nuclei were not infrequent. Necrotic areas were present. With these properties the tumor was considered as high grade malignant pleomorphic mesenchymal tumor. Immunohistochemically, the tumor cells showed strong cytoplasmic staining with CD68, a histiocyt marker. Therefore, histopathological diagnosis was MFH. Figures  a-bth month, cranial metastasis was detected and the patient died in the postoperative 13th month.In the early postoperative period, recurrence was observed. The patient was applied adjuvant chemotherapy. In the postoperative 11Tumors with a sternum origin are a very rare type of primary thoracic wall tumor. Tumors of the sternum usually have a malignant nature. The most common histopathological diagnosis is chondrosarcoma . Althouget al in 1948 defined the criteria for post-radiation bone sarcoma. The requirements are: (a) evidence of an initial distinct malignant tumor different from the subsequent sarcoma, (b) development of the second malignant tumor in an irradiated field, (c) long interval between radiation and development of sarcoma and (d) histological confirmation of sarcoma [Ionized radiation is clearly known to trigger sarcoma formation . Cahan e sarcoma . This caet al have presented a similar patient in whom the preoperative diagnosis could not be established through percutaneous needle biopsy and due to the destruction in the sternum, complete surgical resection was preferred in the diagnosis and treatment of the patient [In establishing histopathological diagnosis, percutaneous fine needle biopsy is preferred because it is easily applied and has low risk of complications. However, variable morphological characteristics of MFH may render diagnosis challenging . Nonaka  patient . NeverthFollowing the diagnosis of malignant primary chest wall tumors, surgical resection of a wide area is required. Despite various views on the extent of resection area, many earlier studies have recommended en bloc resection of the tumor, covering an area of 4 cm from all the sides along with the structures such as the lungs, thymus, and pericardial tissues that may be invaded by the tumor ,10. By rThe recurrence in the postoperative any follow-up period delineates the need for a sufficient resection margin all around the lesion during the surgery. Neoadjuvant chemotherapy can decrease the unnecessary resection around the mass as the margins of which can be shrunken after the neoadjuvant chemotherapy. In our patient, the diameter of the tumor decreased by 3 cm and findings of invasion to the mediastinal structures disappeared after neoadjuvant chemotherapy. It seemed that en bloc resection of the tumor with a vital tissue margin of 4 cm was not totally sufficient in our case due to recurrence after surgery although the size of the tumor had gotten smaller after neoadjuvant chemotherapy. Perhaps, the preoperative size of the tumor should have been considered as the basal measurement, and the decision for the resection extent should be marked as 4 cm vital tissue encircling the original mass before chemotherapy. Taking this into consideration, resection margins should have been like 7 cm of vital tissue from the center of the original mass in our case.Neoadjuvant chemotherapy was an effective method in this related case, and we recommend its use in such cases. In planning the surgical resection of the tumor after neoadjuvant chemotherapy, when possible, the size of the tumor before chemotherapy should be considered as the initial size and surgical margins should be determined accordingly. Complete surgical resection is the desired outcome after neoadjuvant chemotherapy which might provide downsizing as happened in our case saving vital tissues to be resected. En bloc resection of the tumor occupying an area of 4 cm vital tissue apart from all along the wound margins with the structures such as the lungs, thymus, and pericardial tissues that may be invaded by the tumor. Afterwards, total closure of the defect by reconstruction using synthetic materials like meshes should be provided to protect the structural stability.To sum up, it seems neoadjuvant chemotherapy is an effective method in MFH cases before performing surgical resection. Besides, we believe that further studies about its indication are still being warranted in large series in this field.MFH: Malignant fibrous histiyocytoma; CT: Computerized Tomography.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.BK was involved in study conception and design and reviewing previous research. GG was involved in scquisition of data and drafting of manuscript. BE was involved in study conception and design. BB was involved in study conception and design. SE was involved in study conception and design and preparing photographs. KD was involved in analysis and interpretation of data. US was involved in critical revision and project coordination.


Brown tumors are rare focal giant-cell lesions that arise as a direct result of the effect of parathyroid hormone on bone tissue in some patients with hyperparathyroidism. Brown tumors can affect the mandible, maxilla, clavicle, ribs, and pelvic bones. Therefore, diagnosis requires a systemic investigation for lesion differentiation.We present a 42-year-old Greek woman, with a rare case of brown tumor of the maxillary sinus due to primary hyperparathyroidism. Primary hyperparathyroidism is caused by a solitary adenoma in 80% of cases and by glandular hyperplasia in 20%.Differential diagnosis is important for the right treatment choice. It should exclude other giant cell lesions that affect the maxillae. Brown tumors are rare sequelae of hyperparathyroidism. The lesions localize in areas of intense bone resorption, and the bone defect becomes filled with fibroblastic tissue. These tumors have a brown or yellow hue . Brown tHyperparathyroidism is frequently caused by the development of a parathyroid adenoma and less often by hyperplasia or a carcinoma. Some parathyroid adenomas and hyperplasias are familial (5% of cases), and others are part of multiple type I, IIa, and IIb endocrine neoplasias .In a review of 220 patients, Rosenberg and Guralnick found that 10 patients (4.5%) had a mass involving one or both jaws as their presenting complaint . Brown tMost patients with hyperparathyroidism are asymptomatic. Hypercalcemia is often discovered incidentally during routine laboratory testing; hypophosphatemia and increased alkaline phosphatase levels in blood may also be seen . Any of A 42-year-old Greek woman was referred to the Department of Otolaryngology of Chania General Hospital, complaining of facial pain and deformity, and a radiographic finding of a round, radiolucent, and osteolytic, bone-expanding lesion in the anterior part of the right maxillary sinus with invasion of the adjacent floor of the orbit, anterior ethmoids and nasal cavity Figures  and 2. T0 endoscope, revealed medialization of the right lateral nasal wall with no signs of mucosal alteration.On physical examination, the patient appeared well. Her head and neck were normal; no cervical masses were palpated. Her lungs, heart, breasts, and abdomen were normal, as was her urine. Hematocrit was 39.8%; white-cell count was 6800/µL, with a normal differential count; platelet count, prothrombin time, and partial-thromboplastin time were normal. Rigid nasal endoscopy, with a 0Under general anesthesia, an excision biopsy was performed using the Caldwell-Luc approach. The mass had a submucosal origin from the floor of the orbit, infiltrating the lateral nasal wall, with a diameter of approximately 2 cm. The mucosa over the mass was intact and after its excision, erosion of the floor of the orbit was detected with prolapsed periorbital fat. The opening was repaired with an underlay application of dura tissue which was immobilized with tissue glue. Histological sections showed a lesion with regions of discrete bone resorption with osteoclast activity, areas with newly formed bone tissue, and a loose fibrillar matrix with deposits of hemosiderin Figure . MultinuBlood tests after histology demonstrated elevated calcium (13.3 mg/dL) and parathyroid hormone (PTH) concentrations (920 pg/mL). Phosphorus was 1.9 mg/dL, alkaline phosphatase was 227 U/L ; the urea nitrogen, creatinine, glucose, bilirubin, uric acid, protein, albumin, globulin, serum aspartate aminotransferase, and thyroid-stimulating hormone levels were all normal. Sodium was 139 mmol, and potassium was 5.5 mmol. Carcinoembryonic antigen was less than 1 µg/L, and serum immunoelectrophoresis was normal. The concentrations of IgG, IgA, and IgM were normal. This suggested the diagnosis of primary hyperparathyroidism initially manifesting as a brown tumor of the maxilla. Postoperative explorations with magnetic resonance imaging (MRI) scans and gadolinium infusion confirmed the existence of an underlying parathyroid adenoma in the upper left parathyroid gland as the cause of the condition. The patient was referred to the outpatient clinic of the Department of Endocrinology, at the University Hospital of Crete, for examination of her parathyroid function.Various anatomopathological entities, both benign and malignant, can appear as bone-expanding or lytic lesions in the facial bones . In the Bone-expanding giant cell lesions that can arise in the jaw bones include giant cell tumor, giant cell reparative granuloma, cherubism and brown tumor. As it is difficult to distinguish brown tumors from other giant cell lesions on the basis of histology or radiology examination, the clinical diagnosis is made based in relation to hyperparathyroidism -6]. In . In 6]. et al. [The incidence of bone lesions in patients with hyperparathyroidism has fallen from 80% to a current 15%, a reduction that is attributed to better hypocalcemia monitoring in asymptomatic patients, and to the wider use of biochemical analyses . In spitet al.  reportedIt is important to point out that brown tumors are non-neoplastic lesions that are very similar to giant cell tumors, but in the context of hyperparathyroidism, they are considered reparative granulomas and they do not have the malignant or neoplastic potential of real giant cell lesions. The symptoms caused by these lesions depend on their size and location. In the maxilla, they can cause pain or deformity, as in our patient. In other cases, the lesions were asymptomatic and the diagnosis occurred accidentally as a result of a radiological examination. When a tumor of the maxilla has been diagnosed as a giant cell tumor, hyperparathyroidism should be ruled out to exclude the possibility that it is a brown tumor. Other differential diagnoses include the reparative granuloma of giant cells, giant cell tumors, and fibrous dysplasia. A definitive diagnosis is only possible on comparison of the clinical, radiological and biochemical analyses. Brown tumors exhibit no pathognomonic histologic changes. Examination will reveal a dense fibroblastic stroma, areas of cystic degeneration, osteoid, microfractures, hemorrhage, macrophages with hemosiderin, and multinucleated osteoclastic giant cells. Similar changes may occur in fibrous dysplasia, true giant-cell tumors, and reparative granulomas .Differentiating between a brown tumor and other giant-cell tumors may be very difficult, even with histology. Fibrous dysplasia affects the bones of the face, and it is most common among young women. Histology reveals trabecular bone with a stroma rich in fibrous tissue and multinucleated giant cells that are visible in areas of hemorrhage secondary to focal degeneration . True giet al.[et al.[et al.[There is agreement as to the treatment of choice for primary hyperparathyroidism being parathyroidectomy; however, opinions are divided as to the treatment of bone lesions. Authors such as Scott et al. believe l.[et al. recommenl.[et al. recommenDue to recent improvements in analytical techniques, the diagnosis of hyperparathyroidism usually occurs when the disease is in an asymptomatic phase, and the incidence of patients with advanced bone lesions is rare. The treatment of choice for bone lesions is a parathyroidectomy; however, in the case of larger lesions, or those that persistently grow in spite of treatment, or those lesions causing incapacity, curettage and associated enucleation should be conducted.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.All authors provided an equal intellectual contribution to this manuscript. PE and CTH analyzed and interpreted the patient data regarding the tumor. DT performed the histological examination of the tumor. The clinical notes were reviewed by CEP. All authors read and approved the final manuscript.


Uterine leiomyomas are the commonest gynecological neoplasms. The typical appearances of leiomyomas are easily recognized on imaging. However, the atypical appearances that follow degenerative changes may cause confusion in diagnosis. Here we present the USG and MRI findings in two different patients with uterine leiomyomas that had undergone cystic degenerative changes, mimicking a complex adnexal cyst of ovarian origin in one case and a large myometrial cyst in the other.A 35-year-old woman presented with a history of lower abdominal pain and distension for a period of around 6 months. On abdominal examination, vague right abdominal fullness was felt. Per vaginal examination revealed an adnexal mass. A pelvic USG examination revealed a large, complex, predominantly cystic mass, approximately 10.0 × 8.5 × 7.0 cm in size, with multiple fine internal septae, arising from the right side of the pelvis and extending into the upper abdomen . The uteMRI showed a midline, well-circumscribed cystic mass, with multiple fine internal septae and signal intensities consistent with fluid. The images revealed continuity of the cyst wall with the remainder of the uterine myometrium, thus indicating a myometrial origin Figures –4. The sThe patient underwent laparotomy. A large mass was found to arise from the anterior uterine body; the ovaries were not involved. The mass was resected and this was followed by hysterectomy. Histopathological examination revealed a leiomyoma with extensive cystic degeneration.A 38-year-old lady presented with a history of long-standing menorrhagia. Abdominal and pelvic examinations were normal. USG evaluation revealed a well-circumscribed, anechoic lesion in the posterior uterine wall, measuring approximately 10.0 × 8.0 × 6.2 cm in size . Both ovMRI revealed a cyst with a hypointense signal on T1W images and hyperintense signal on T2W images Figures  and 7. TThe patient underwent hysterectomy and histopathological examination revealed a uterine fibroid with marked cystic degeneration.Leiomyomas are the commonest uterine neoplasms, occurring in around 20-30% of women in the reproductive age group.–3 They a11USG is the primary modality for diagnosing clinically suspected uterine fibroids. USG commMRI plays a crucial role in determining the origin and nature of a pelvic mass in cases with inconclusive USG features. MRI appe3In conclusion, although fibroids usually have a characteristic USG appearance, degenerating fibroids can have variable patterns and pose diagnostic challenges. However, clinical and USG correlation, together with a knowledge of the variable USG appearances of degenerating fibroids, will generally lead to the correct diagnosis. A pedunculated, subserosal uterine leiomyoma with extensive cystic degeneration may mimic an ovarian tumor. MRI may be helpful in complicated cases.373


Numerous cases are described of patients in whom foreign objects were found after surgery. Foreign body granuloma caused by retained surgical sponge, also called gossypiboma, mostly occur in the abdominal cavity but very seldom in limbs.A 29-year-old Caucasian man presented with asymmetrical walking pattern and progressive pain in his leg, which was severely injured and amputated seven years before. A firm swelling of soft tissue with calcifications was localized in the stump. Roentgenogram and MRI showed a retained surgical sponge with calcifications. Open surgery was performed and a well-encapsulated, brownish soft-tissue tumour containing serous fluid was found in which the remnants of a surgical sponge of 40 × 40 centimeters was identified and removed. Infectious complications characterized the postoperative course for which multiple surgical procedures were needed to create a definitive healing of the stump.A surgical sponge left behind in an amputated leg may lead to fibroma, destruction, osteolysis and calcification. In our case the gauze lead to mild dysfunction of the prosthetic leg, asymmetrical walking pattern, phantom pain and calcification and osteolysis on roentgenogram. Numerous cases are described of patients in whom retained surgical sponges were detected after surgery, months or even years after the initial operation. Retention of these foreign bodies may lead to formation of soft tissue mass with possible bony involvement . PreviouA 29-year-old Caucasian man was seen in our department for a second opinion because of asymmetrical walking pattern and progressive sourness in his amputated leg. He was referred from a rehabilitation center where a standard roentgenogram showed evidence of a gauze in situ near the distal femur stump with progressive ossifications Figure .His medical history noted a severe high energy trauma seven years ago. He had sustained multiple injuries among which a severe crush injury of the left leg with heavy bleeding for which an acute amputation was performed.After six weeks he could be discharged from the hospital and was measured an advanced prosthetic leg for optimal rehabilitation. It took him 3 months to walk without aids. Two years later he fell on his stump in the bathroom. An X-ray was made of the left upper leg stump to rule out any fracture. The radiologist reported no fracture, but a swelling of soft tissue with calcifications at the femoral cutting edge. The report also mentioned that at the time of roentgenography, the stump was covered with a gauze, because a radio-opaque marker was visible on the X-ray. In the conclusion of the X-ray report, no mention was made on the gauze fibroma.His painful stump recovered in a few weeks but five years later, he consulted his rehabilitation physician for asymmetrical walking pattern with soreness of the stump. A standard roentgenogram revealed progressive calcifications compared to the previous study. The radio-opaque marker was recognized as a retained surgical gauze which was left behind during initial surgery. The progressive ossifications were thought to cause his complaints. He was directed to our department for re-evaluation. Clinical examination showed an otherwise healthy man with a prosthetic leg with vacuum fitting. His walking pattern was slightly asymmetrical due to partial weight-bearing of his artificial leg. His left leg stump showed obvious thickening at the distal end. No painful or sharp masses could be palpated and no skin defects were noted, let alone multiple scars from previous trauma and surgery.To exclude malignant tumor growth, magnetic resonance imaging showed a benign granuloma of 12.6 × 10.0 centimeters with remodelling of the ossal part of the femur around the tumor. This was interpreted as a physiological reaction of the leg to encapsulate the foreign body. The suspected surgical sponge was not clearly identified from the surrounding granuloma.Most effective treatment options would be to completely remove the calcifications including granuloma with surgical sponge. The patient however had experienced much advantage from the firm swelling of his stump and did consent. His prosthetic leg fitted well in time because of these progressive ossifications around the gauze. Therefore it was decided to only remove the gauze, but not the ossifications nor the granuloma, to remove the trigger for further progression of the ossifications, but to maintain the form of the stump.staphylococcus aureus was necessary. The postoperative course was further complicated by infectious complications and shortening of the femoral end with removal of all calcifications could not be avoided (Figure At surgery, the distal end of the stump was opened through an old scar. A well organized, firm, brownish tumor was opened which appeared to have a wall of around two centimetres. Brownish, serous fluid was drained and sent for culture of micro-organisms. Remnants of a partly disintegrated surgical sponge of 40 × 40 centimeters were removed with curettage of the granuloma Figure . The woud Figure . DisturbIn literature only few cases are described of retained gauze in a limb, years after initial surgery ,4-7. If Radiological differentiation between a gossypiboma and a malignant musculoskeletal tumour is difficult, because they might present with variable spectrum of skeletal changes as osteolytic, periostal and osteoblastic reactions. Retained sponge may be overlooked, unnecessarily invasive investigations might take place, or an erroneous diagnosis may be made ,3,5,6. MIt is obvious that in this case the retained gauze was apparently found on radiography two years after amputation when he fell on his stump in the bathroom and a radiogram was performed to rule out a fracture, but it was not interpreted as a retained surgical sponge and thus no treatment plan was deployed. Apparently the clinician who referred him to the radiologist did not think of a gossypiboma. Also, the important information on the fibroma in the stump caused by the gauze was not mentioned in the conclusion. The patient was referred to another hospital for advice, where no treatment plan was made. Insufficient communication between physicians did not lead to adequate treatment. Unfortunately, other case reports do not mention whether radiological investigation preceded discovery of the retained gauze at surgery or whether there was miscommunication between treating physicians. Underreporting of gossypibomas and complications in general is common in medical literature ,9.A retained surgical sponge after amputation may lead to fibroma. In this case the gauze lead to mild dysfunction of the prosthetic leg with asymmetrical walking pattern due to pain. More importantly, when abnormal findings on previous radiographs would have been interpreted correctly, the gauze could have been removed much earlier, preventing the massive ossifications to occur. This fact again points out the importance to think of gossypiboma whenever radio-opaque markers, fibromas or unexpected ossifications occur on routine radiographs.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.IK was the treating physician while patient was admitted in our department and drafted the manuscript. JF was involved in design of the case report, he conceived the original idea of the case report, conducted the operation detailed and has been involved in critically revising the manuscript.


Cloacal dysgenesis sequence (CDS) is a lethal malformation with a highly variable presentation. CDS is characterized by direct communication between the gastrointestinal, urinary, and genital structures, resulting in a single perineal opening. Prenatal diagnosis of a cloacal anomaly is often difficult because of the highly variable imaging features. Here, we report a case in which a diagnosis of CDS was made with fetal MRI on the basis of a meconium-containing, bilobed, abdominopelvic cystic mass communicating with the ureters and the colon. Cloacal malformation is a rare anomaly with a highly variable presentation. The incidence is about 1 in 50,000 live births. Cloacal 3The prenatal diagnosis of a cloacal malformation may allow better planning of pre- and perinatal care, but is difficult because of the highly variable imaging features, depending on the type of malformation and the gestational age.–3 Fetal 5A 29-year-old primigravida underwent routine antenatal USG at another institution at 28 weeks gestation. This revealed a large abdominal cystic mass and oligohydramnios. Her history was otherwise unremarkable. She had not been exposed to any teratogenic agent during pregnancy. Repeat USG at our institution showed a single live fetus with a vertex presentation and a biparietal diameter and femur length corresponding to 28 weeks gestation. A 10 × 15 cm hypoechoic, abdominopelvic cystic mass, containing debris was seen. The bladder was not seen separate from the mass lesion. The mass was pushing the diaphragm, causing lung hypoplasia. The right kidney was enlarged and hydronephrotic, while the left kidney was not visualized separately. The bowel loops were dilated and multiple foci of calcified meconium were seen in the lumen . The amnMRI  was performed to further evaluate the fetus using half-Fourier single-shot turbo spin-echo (HASTE), true fast imaging with steady-state precession (Tru-FISP), and gradient echo T1W sequences. MRI revealed a large, bilobed, abdominopelvic cystic mass . Its walA diagnosis of CDS with left renal agenesis and lumbar meningomyelocele was made. Poor prognostic features included severe oligohydroamnios, pulmonary hypoplasia, and enterolithiasis. The parents were informed of the poor chances of survival and the patient was followed up with serial USG every 2 weeks. Intrauterine demise of the fetus was detected at 34 weeks gestation. Labor was induced with 50 μg misoprostol. A fetus weighing 1.9 kg, with an extremely protuberant abdomen, imperforate anus, and ambiguous genitalia was delivered. Gross examination revealed a smooth perineum, without patent urethral, vaginal, and anal openings; enlarged wrinkled clitoral-like structure; and talipes equinovarus. Postmortem examination revealed a single enlarged right kidney, with double ureters draining into a large pelvic cystic lesion . The larCloacal anomalies can have varied manifestations, ranging from a persistent cloaca to complete breakdown of the cloacal membrane with exstrophy, failure of fusion of the genital tubercles, and omphalocele.4 CDS is The cloaca forms from the developing tail fold at 3 weeks through the confluence of the allantois and the hindgut.3 The cloa32in utero, and its presence should suggest the presence of a fistula between the urinary and the gastrointestinal tracts.[21Antenatal USG findings include transient fetal ascites, a bilobed debris-filled, abdominopelvic cystic structure, poorly or nonvisualized bladder, oligohydramnios, cystic or dysplastic kidneys, and hydronephrosis.12 A char tracts.2 The progtracts.21 OligohydFetal MRI has recently been used in the diagnosis of cloacal anomalies.81014 MRI8105In our case, CDS was diagnosed prenatally on the basis of the presence of a bilobed, cystic, abdominopelvic mass containing meconium and having showing communication with the ureter and the colon. MRI not only defined the bilobed pelvic cyst but also demonstrated the possible communication with the bowel and the ureter, which helped us make a more precise diagnosis prenatally.In summary, CDS should be considered in the differential diagnosis of a midline, cystic, abdominopelvic mass in a female fetus. Prenatal USG diagnosis of this entity is difficult. Antenatal MRI plays an important role in making a precise prenatal diagnosis by demonstrating the communication between the genitourinary and gastrointestinal tracts. MRI is also more sensitive than USG for detecting the presence of meconium.


Spontaneous rupture of the urinary bladder is a rare event. Patients usually present with features of peritonitis and diagnosis is usually made at operation. The morbidity and mortality rate is very high in these groups of patients.We present a case of a 47-year-old caucasian woman who was known to have transitional cell carcinoma of the urinary bladder who presented with features of peritonitis. An exploratory laparotomy revealed free perforation of the urinary bladder. The perforation was closed. However, on the second post-operative day she started draining urine from the abdominal drain and was taken back to the operating theatre. The stitches in the urinary bladder had given off and she underwent radical cystectomy along with double barrel cutaneous ureterostomies. Peritoneal biopsies revealed disseminated transitional cell carcinoma in the peritoneum. She made a slow postoperative recovery.Perforation of the urinary bladder should be considered in patients presenting with peritonitis particularly with a previous history of urinary bladder cancer. Rupture of the urinary bladder is an uncommon and life threatening event. Prompt diagnosis followed by surgical intervention is the key for successful outcome. Often, there are obscurities in establishing exact diagnosis preoperatively which may lead to a very high mortality rate. It is also true that such patients are in advanced stage of their disease, a very few survive more than one year following diagnosis.A 47-year-old Caucasian woman presented as an emergency with generalized abdominal pain. She was diagnosed with a grade 3 transitional cell carcinoma of the postero-lateral wall of the urinary bladder, which was resected endoscopically seven months ago. This was followed by adjuvant intravesical mitomycin. She does not have any co-existent medical problems. She used to smoke 30 cigarettes per day. Her mother died due to metastatic urinary bladder cancer.Clinical examination did not reveal any jaundice or anaemia. She was in obvious distress with abdominal pain. Her observations were as follows: temperature 37.8°Celsius, blood pressure was 110/70 mmHg, pulse 120 beats/min with a respiratory rate of 20/min. Abdominal examination revealed features suggestive of generalized peritonitis. Laboratory tests showed haemoglobin 11.4 g/dL, white cell count 34,300 cells/mm3 of blood, C-reactive protein > 300 and amylase 15U/L. The rest of her blood results were normal. Plain radiographs of chest and abdomen did not reveal any signs of perforation or intestinal obstruction. A urinary catheter was inserted which drained 1100 ml straight away and no further output. She was promptly taken for an exploratory laparotomy which revealed 500 ml of urine intraperitoneally with free perforation of the urinary bladder. The perforation was closed with interrupted Vicryl®  3/0 stitches. A thorough washout was performed. An abdominal drain was inserted and the wound closed. On the second post-operative day the abdominal drain was draining urine and she was taken back to the operating theatre. The stitches in the urinary bladder had given off and she underwent radical cystectomy along with double barrel cutaneous ureterostomies. Peritoneal biopsies revealed disseminated TCC in the peritoneum. She made a slow postoperative recovery.Spontaneous rupture of the urinary bladder is an uncommon and life threatening event. Prompt diagnosis followed by surgical intervention is the key for successful outcome. Often, there are obscurities in establishing exact diagnosis preoperatively leading to a very high mortality rate. It is also true that such patients are in advanced stage of their disease, a very few survive more than one year following diagnosis.Studies and case reports in the literature were identified by PubMed search between the years 1967-2007 using the following free text keywords: bladder, carcinoma, spontaneous, perforation, and peritonitis from the year 1967 in the English literature. . Budd JS [The most common causes of atraumatic rupture of urinary bladder are chronic inflammation, bladder outflow obstruction and cancer . Budd JS Budd JS  in 1988  Budd JS , Albeit, Budd JS . GlashanClinically most of patients presented with lower abdominal pain with associated symptoms of dysuria, unable to void, anuria and haematuria. In the majority of cases the symptoms of urinary tract infection (UTI) were the initial complaints and this was later accompanied by peritonism. A clinical diagnosis of acute abdomen was made in all the cases, which were reviewed.An accurate preoperative diagnosis of urinary bladder rupture was made only in two out of fifteen case reports ,5. InterThe site of the perforation was dependant on where the tumour was situated as shown from previous studies. The possible pathogenesis of bladder rupture in bladder cancer is precipitation of perforation on the weakened body wall by the tumour. Although the most frequent location for intraperitoneal perforation was the dome or the posterior wall of the bladder .ComputedBasavaraj et al recommend that conservative management of spontaneous perforation of the bladder following radiotherapy, with antibiotic and prolonged catheterization is a better option than surgical intervention .Transitional cell carcinomas (TCC) account for about 90% of all bladder tumours, where as squamous cell carcinoma comprise less than 5%. In this review we found eleven cases of TCC and eight cases of SCC which have perforated suggesting squamous cell carcinomas are more likely to perforate than TCC. These findings were also concurred by Rasmusen JS [Chronic cystitis in the presence of indwelling catheters or calculi is associated with increases risk of SCC (non-bilharzail type) of the urinary bladder .The prognosis of spontaneous bladders rupture due to carcinoma is very poor. Most of patients, in this review, died within months ranging from 10 days to 8 months. The mortality rate can range from 25% to 80% depending up time of diagnosis ,11.Patients with rupture of urinary bladder usually present with symptoms and signs of peritonitis. A history of unexplained urinary tract symptoms prior to the acute episode is not uncommon in most of these patients. A high index of suspicion is essential in the presence of urinary symptoms and signs suggestive of peritonitis in a patient with bladder cancer. Rupture of urinary bladder must be included in the differential diagnosis of acute abdomen. This is a rare but potentially fatal condition with a mortality rate more then 80%.


Sclerosing mesenteritis is a rare, benign, and chronic fibrosing inflammation disease with unknown etiology that affects the mesentery of small bowel and colon. The disease has two well-established histological types: the acute or subacute form known as mesenteric panniculitis and the chronic form known as retractile or sclerosing mesenteritis. Because the sclerosing mesenteritis is lack of special clinical manifestation and typical signs, so the patients are very easy to be misdiagnosed. The correct diagnosis of sclerosing mesenteritis depends on pathological examination and exploratory laparotomy. We report a case of sclerosing mesenteritis in a 52-year-old male who presented with chronic abdominal pain and intraabdominal mass. This patient had a long-term and heavy drinking history. He was misdiagnosed as celiac teratoma by CT examination and then underwent an exploratory laparotomy at March 2 2004. A mass, its diameter being about 5 cm, was detected in mesentery of distal ileum. Although a few small intestines tightly adhered on the mass, the involved intestine had no obstruction. The intraoperative biopsy indicated that it was an inflammatory mass. The mass and adhered intestines were removed. He was diagnosed with sclerosing mesenteritis by histopathological examination of paraffin section. After operation, this patient went well and lives without recrudescence at the time we wrote this paper. On rare occasions, it may involve the mesocolon, peripancreatic region, omentum, retroperitoneum, or pelvis . Sclerosst cases .In most patients with sclerosing mesenteritis, the condition consists of a mixture of chronic non-specific inflammation, fat necrosis and fibrosis. So their clinical manifestation can vary. Patients may present with abdominal pain, intestinal obstruction, fever, chylous ascites, a mass, constipation or diarrhea ,5. BecauA 52-year-old male patient presented with chronic abdominal pain for about 6 mo and intraabdominal mass for about 1 mo. The abdominal pain, mainly located around navel, was intermittent and mild. The mass, located in the right lower quadrant, was mobile, smooth, rigid and about the size of a fist. The laboratory profile of routine blood test, renal and hepatic function tests were normal. Abdominal CT scan demonstrated a solid soft-tissue mass with calcification in the right lower abdomen, which correlated with small bowel and mesentery Figure , 4. So tSclerosing mesenteritis is a rare disease of unknown etiology that is characterized by tumor-like mass composed of chronic nonspecific inflammation, fat necrosis and fibrosis -4,7. ChrEven until now, just about 300 cases have been reported in the world literatures . AccordiAt the present time, the scholars still have not reached a consensus on the treatment of sclerosing mesenteritis -8. Some Literatures revealed that sclerosing mesenteritis have a favorable prognosis and may be self-limiting -4,14. ThThe authors declare that they have no competing interests. We have obtained consent for publication in print and electronically from the patient. We all authors have seen and approved the submitted version of this manuscript. There was not a medical writer or editor involved in the generation of our manuscript. We are assured that the manuscript has not been published or submitted for publication elsewhere except as a brief abstract in the proceedings of a scientific meeting or symposium.GG, WSL and WXM contributed equally to this work; GGL and WSL designed the research; GGL and ZFX collected the clinical data and wrote the manuscript; RL and LDC collected the pathological data; WSL, WXM and ZFX revised the manuscript.The consent was obtained from the patient for publication of this case report and accompanying images.