Primary intestinal tuberculosis is a rare variant of tuberculosis. The preferred treatment is usually pharmaceutical, but surgery may be required for complicated cases.Mycobacterium tuberculosis. Both patients were given anti-tuberculosis therapy and their post-operative follow-up was uneventful.We report two cases of primary intestinal tuberculosis where the initial diagnosis was wrong, with colonic cancer suggested in the first case and a Crohn's disease complication in the second. Both of our patients were Caucasians of Greek nationality. In the first case (a 60-year-old man), a right hemicolectomy was performed. In the second case (a 26-year-old man), excision was impossible due to the local conditions and peritoneal implantations. Histopathology revealed an inflammatory mass of tuberculous origin in the first case. In the second, cell culture and polymerase chain reaction tests revealed Gastrointestinal tuberculosis still appears sporadically and should be considered in the differential diagnosis along with other conditions of the bowel. The use of immunosuppressants and new pharmaceutical agents can change the prevalence of tuberculosis. Mycobacterium tuberculosis in general, but also because of the difficulty in identifying it in the biopsies taken by endoscopy. It is estimated that only one out of three cases of lower gastrointestinal tuberculosis gives a positive identification of the mycobacterium by culture, and two out of three cases by polymerase chain reaction (PCR) [Based on surveillance and survey data, the World Health Organization (WHO) estimates that 9.27 million new cases of tuberculosis occurred in 2007. Primary intestinal tuberculosis (PITB) is a rare variant of the disease accounting for 1% of the cases in Europe [on (PCR) -5. The dIn this report, we present two cases with primary PTBC. The initial diagnosis suggested in the first case was colonic cancer, and in the second a complication of CD.3, and mild hypoalbuminemia (3.0 g/dL). Liver and kidney functions were within normal range, and results of a chest X-ray were unremarkable. During his hospitalization, he presented with low fever (37.1°C to 37.6°C) and complained of deterioration of his abdominal pain. A contrast-enhanced computed tomography (CT) scan was performed, and revealed a mass located in the region of the cecal valve , a white blood cell count of 8000 cells/mme Figure . ColonosA typical right hemicolectomy was performed Figure  and the A 26-year-old Greek Caucasian man was referred to our out-patient department with episodes of abdominal pain, loss of weight, fever, anorexia and general weakness for the past six months. He had a history of CD from the age of 19, and he was being treated with infliximab (5 mg/kg). During the past six months he had been admitted twice to other hospitals with the same symptoms and discharged with the diagnosis of acute phase CD. A physical examination revealed abdominal tenderness and the presence of a palpable mass in the right ileac fossa. Laboratory test results revealed mild anemia  and low total albumin levels (6.1 g/dL). An abdominal contrast enhanced CT scan was performed, revealing a mass in the cecum and free peritoneal fluid  our patient remains free of symptoms.On laparotomy, a large mass of the cecum and peritoneal implantations were revealed. Biopsies were taken and a bypass procedure (ileo-transverse colon anastomosis) was performed Figure . Ziehl-NM. tuberculosis. PITB may occur either as primary or secondary infection. The assumed routes of infection of the gastrointestinal tract are ingestion, hematogenous spread from the lungs, from infected lymph nodes and direct spread from adjacent organs. Rarely, Mycobacterium bovis is the cause due to unpasteurized milk and milk products [The principle cause of PITB is products . Manifesproducts ,8.More specifically, the ileo-cecal area is reported to be the area most commonly involved in intestinal tuberculosis ,8-12. Thet al. referred an additional finding of multiple fibrous bands arranged in a haphazard fashion, forming pockets [Colonic tuberculosis may present as an inflammatory stricture, hypertrophic lesions resembling polyps or tumors, segmental ulcers and colitis or, rarely, diffuse tuberculous colitis . Diagnos pockets .With regard to the imaging findings in abdominal tuberculosis, the simple abdominal X-ray offers little or no help at all, as the findings of bowel obstruction or perforation that might be seen are non-specific, and the calcification of mesenteric lymph nodes, while rare, is unlikely to lead to the correct diagnosis if high awareness for the disease is not present. The main imaging techniques used are ultrasonography, CT, MRI and positron emission tomography. The common imaging features are: enlarged para-aortic nodes, asymmetric bowel wall thickening, ascites, inflammatory masses of the bowel wall lymph nodes and omentum, narrowing of the terminal ileum with thickening and gaping of the ileo-cecal valve, 'white bowel' sign due to lymphatic infiltration and 'sliced bread sign' due to fluid surrounding bowel caused by inflammation of the bowel wall .et al. caseation may be absent or be present only in the lymph [The diagnostic procedure of choice for PTBC is colonoscopy and biopsy . Apart fhe lymph . This fihe lymph ,12,14. ICulture of the biopsy material may be helpful , howeverThe differential diagnosis includes a broad spectrum of diseases. The clinical, radiological and endoscopic picture is most likely to be confused with neoplasms or CD, and infrequently with other conditions including amoeboma, Yersinia infection, gastrointestinal histoplasmosis and peri-appendiceal abscess . FinallyTuberculosis is a re-emerging problem, concerning not only countries with high incidence, but Western countries as well. Constant demographic changes, the movement of populations, the incidence of HIV infection and the use of immunomodulator drugs mark the beginning of a new era with new challenges, where the clinical doctor is called upon to be highly aware and always up to date with new guidelines. Intestinal tuberculosis is a diagnostic puzzle, especially in low endemic countries where less experienced clinical doctors are only bibliographically familiar with the disease and its appearance, and clinical manifestation can imitate a broad spectrum of diseases. Attaining a cure can prove to be quite difficult as drug resistant strains seem to be met increasingly often. Surgery should be kept as the last resort and used only in complicated cases. It is our opinion that tuberculosis is not only a problem of underdeveloped countries, and that it is going to trouble the world further in the future.Written informed consent was obtained from both patients 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.AM: study design, drafting the manuscript and revising it critically. VNP: study design, drafting the manuscript. SP: study design, drafting the manuscript. TSP: study design, drafting the manuscript. AC: study design, drafting the manuscript. All authors read and approved the final manuscript.


Colonic lipomas are uncommon nonepithelial neoplasms that are typically sessile, asymptomatic and incidentally found during endoscopy, surgery, or autopsy. We present a very rare case of a 34-year-old female patient with symptomatic pedunculated cecal lipoma causing intermittent colo-colonic intussusception. Despite adequate imaging studies, definite preoperative diagnosis was not established and the patient underwent exploratory laparotomy. Intraoperatively, intussusception of the cecum into the ascending colon was found and right hemicolectomy was performed. Macroscopic assessment of the resected specimen showed the presence of a giant cecal pedunculated polypoid tumor with features of lipoma, causing intussusception. Histopathological examination confirmed the diagnosis of pedunculated cecal lipoma. Gastrointestinal lipomas are uncommon nonepithelial neoplasms that can be found anywhere along the entire length of gastrointestinal tract. Typically, they are asymptomatic and incidentally found during endoscopy, surgery, or autopsy. Only 25% of them develop symptoms, especially when their diameter exceeds 2 cm. Colonic lipoma typically presents as a sessile polypoid mass. Infrequently, lipomas of the colon are pedunculated, with ulcerated or necrotic overlying mucosa. We present an extremely rare case of a symptomatic pedunculated lipoma of the cecum with ulcerated mucosa causing intermittent colo-colonic intussusception that was surgically resected.A 34-year-old female patient was admitted to our department suffering from intermittent diffuse abdominal pain over the last two months. Her medical history was unremarkable. On examination the abdomen was mildly distended, with rebound percussion tenderness in the right iliac fossa. Routine blood tests were within normal ranges. Double-contrast barium enema examination revealed an ovoid filling defect in the cecum and ascending colon . SubsequColonic lipomas are rare nonepithelial neoplasms with an incidence ranging from 0.035% to 4.4% in relation to all polypoid lesions of large intestine ; howeverTreatment options of colonic lipomas are various and include endoscopic and surgical procedures. Endoscopic resection is generally recommended for lipomas with a diameter smaller than 2 cm or pedunculated lipomas with thin stalk , as in t


Intestinal ischemia is an abdominal emergency that accounts for approximately 2% of gastrointestinal illnesses. It represents a complex of diseases caused by impaired blood perfusion to the small and/or large bowel including acute arterial mesenteric ischemia (AAMI), acute venous mesenteric ischemia (AVMI), non occlusive mesenteric ischemia (NOMI), ischemia/reperfusion injury (I/R), ischemic colitis (IC). In this study different study methods  will be correlated in the detection of mesenteric ischemia imaging findings due to various etiologies.Basing on our institutions experience, 163 cases of mesenteric ischemia/infarction from various cases, investigated with CT and undergone surgical treatment were retrospectively evaluated, in particular trought the following findings: presence/absence of arterial/venous obstruction, bowel wall thickness and enhancement, presence/absence of spastic reflex ileus, hypotonic reflex ileus or paralitic ileus, mural and/or portal/mesenteric pneumatosis, abdominal free fluid, parenchymal ischemia/infarction .To make an early diagnosis useful to ensure a correct therapeutic approach, it is very important to differentiate between occlusive  and non occlusive causes (NOMI). The typical findings of each forms of mesenteric ischemia are explained in the text.The radiological findings of mesenteric ischemia have different course in case of different etiology. In venous etiology the progression of damage results faster than arterial even if the symptomatology is less acute; bowel wall thickening is an early finding and easy to detect, simplifying the diagnosis. In arterial etiology the damage progression is slower than in venous ischemia, bowel wall thinning is typical but difficult to recognize so diagnosis may be hard. In the NOMI before/without reperfusion the ischemic damage is similar to AAMI with additional involvement of large bowel parenchymatous organs. In reperfusion after NOMI and after AAMI the CT and surgical findings are similar to those of AVMI, and the injured bowel results quite easy to identify. The prompt recognition of each condition is essential to ensure a successful treatment. Several pathologies like cancer, diabetes, neurodegenerative and cardiovascular induced by oxidative stress mechanisms occurs frequently in senescence ,2. OxidaBasing on our institutions experience, 163 cases of mesenteric ischemia/infarction from various cases, investigated with CT and undergone surgical treatment were retrospectively evaluated. The following CT findings were considered: patency of the superior mesenteric artery (SMA) or inferior mesenteric artery (IMA), bowel wall thickness (more or less than 3 mm) and enhancement, presence/absence of spastic reflex ileus, hypotonic reflex ileus or paralitic ileus, mural and/or portal/mesenteric pneumatosis, abdominal free fluid, parenchymal ischemia/infarction ; and the following intraoperative findings: presence of pale/congested mesentery, color of the bowel wall, presence/absence of bowel spasm or dilation, presence/absence of abdominal free fluid, kind of fluid in peritoneal cavity (hemorragic or serous), signs of parenchymal ischemia/infarction , extension of the bowel damage. Enhanced CT was performed with 64-detector row configuration . The following technical parameters were used: in 64-rows CT, effective slice thickness of 3.75 mm for plain acquisition, 1.25 mm in the late arterial phase and 2.5 mm in the portal venous phase; beam pitch of 0.938, reconstruction interval of 0.8 mm, tube voltage of 120-140 KVp and reference mAs of 250/700 mA. Automatic tube current modulation was used to minimize the radiation exposure. A standard reconstruction algorithm was used. Patients were instructed not to breath during helical imaging to avoid motion artefacts. All patients received iodinated nonionic contrast material  intravenously at a rate of 3.5 mL/s with a power injector. No patient received oral contrast material.Patients typically present in their 60s to 70s and often have a number of medical comorbidities. In case of occlusive etiology, abdominal pain is the most common presenting symptom (94%) and patients usually complain of abdominal pain out of proportion to the abdominal examination. Other symptoms include nausea (56%), vomiting (38%), diarrhea (31%), and tachycardia (31%). In advanced phase, the patient develops peritoneal signs of distention, guarding, rigidity, and hypotension-25. NOMIThe diagnosis of AMI can be difficult, because most patients have nonspecific symptoms of abdominal pain. Abdominal pain out of proportion to the findings on physical examination and persisting beyond 2 to 3 hours is the classic pre- sentation . At leasThanks to the development of animal model of mesenteric ischemia, it was possible to explore the physiopathological process that conducts to intestinal infarction, underlining that a specific timing of lesions occurs and it is very important to define this to ensure a correct diagnostic assessment and therapeutic result .Enhanced CT findings are conditioned by the involved tract  by the typology (varying according to the obstructive mechanisms) and by the timing.In the early phase the presence of emboli or thrombi as filling defect in the lumen of the artery could be found Figure . Their iHyperperistalsis and hyperactive bowel sounds on auscultation are evident. In case of laparotomy the bowel appear spastic in response to the ischemic damage, with pale mesentery.In the intermediate phase, blood and fluids are drained by the venous system, and the bowel wall become thin, with a typical "paper thin" aspect ,28; the AVMI account for 10% of cases of intestinal ischemia . ImpaireAt CT the thrombus may be seen in the SMV , in earlNOMI represents the 20-30% of all cases of acute mesenteric ischemia -43 and cIschemia-reperfusion injury (I/R) of the intestine is an important factor associated with a high morbidity and mortality . It may The radiological findings of mesenteric ischemia have different course in case of different etiology. In venous etiology the progression of damage results faster than arterial even if the symptomatology is less acute; bowel wall thickening is an early finding and easy to detect, simplifying the diagnosis. In arterial etiology the damage progression is slower than in venous ischemia, bowel wall thinning is typical but difficult to recognize so diagnosis may be hard. In the NOMI before/without reperfusion the ischemic damage is similar to AAMI with additional involvement of large bowel parenchymatous organs. In reperfusion after NOMI and after AAMI the CT and surgical findings are similar to those of AVMI, and the injured bowel results quite easy to identify. The prompt recognition of each condition is essential to ensure a successful treatment.The authors declare that they have no competing interests.FI: conceived the study, carried out the examinations, analyzed and interpreted the data, drafted the manuscript.AR: conceived the study, carried out the examinations, analyzed and interpreted the data.DB: conceived the study, carried out the examinations, analyzed and interpreted the data.GG: critically revised the manuscript.GDG: critically revised the manuscript.MR: critically revised the manuscript.PF: conceived the study and critically revised the manuscript.RG: conceived the study, analyzed and interpreted the data, critically revised the drafted manuscript.All authors read and approved the final manuscript.FI: Resident in Radiology Training Program at Second University of NaplesAR: Post-Doctoral Fellow in Radiology at Second University of NaplesDB: Resident in Radiology Training Program at Second University of NaplesGG: Resident in Radiology Training Program at Second University of NaplesGDG: Resident in Radiology Training Program at Second University of NaplesMR: Assistant Professor of Radiology, University of Rome "Sapienza"PF: Associate Professor of Radiology at University of TurinRG: Full Professor of Radiology, Second University of Naples


Brain metastases arise in 10%–40% of all cancer patients. Up to one third of the patients do not have previous cancer history. We report a case of a 67-years-old male patient who presented with confusion, tremor, and apraxia. A brain MRI revealed an isolated right temporal lobe lesion. A thorax-abdomen-pelvis CT scan showed no primary lesion. The patient underwent a craniotomy with gross-total resection. Histopathology revealed an intestinal-type adenocarcinoma. A colonoscopy found no primary lesion, but a PET-CT scan showed elevated FDG uptake in the appendiceal nodule. A right hemicolectomy was performed, and the specimen showed a moderately differentiated mucinous appendiceal adenocarcinoma. Whole brain radiotherapy was administrated. A subsequent thorax-abdomen CT scan revealed multiple lung and hepatic metastasis. Seven months later, the patient died of disease progression. In cases of undiagnosed primary lesions, patients present in better general condition, but overall survival does not change. Eventual identification of the primary tumor does not affect survival. PET/CT might be a helpful tool in detecting lesions of the appendiceal region. To the best of our knowledge, such a case was never reported in the literature, and an appendiceal malignancy should be suspected in patients with brain metastasis from an undiagnosed primary tumor. Brain metastases arise in 10%–40% of all cancer patients and are the commonest intracranial tumor . AccordiPrimary appendiceal neoplasms are a rare group of malignancy that constitutes less than 0.5% of all tumors of gastrointestinal origin [A 67-years-old male patient presented to our attention complaining of confusion, tremor and apraxia. His past medical history was unremarkable. On admission, neurological examination was normal. CT scan of the head and subsequent MRI of the brain revealed an isolated right temporal lobe lesion of 4 cm in its major axis, with inhomogeneous contrast enhancement and extensive surrounding edema  both comBrain metastases arise in 10%–40% of all cancer patients and are a significant source of morbidity and mortality, with a median survival ranging from 7 to 12 months . Most coTo date, there are no standard guidelines regarding the various treatment options  or data concerning overall survival and clinical outcome , 9, 10, We described an extremely rare case (to the best of our knowledge never reported in the literature) of brain metastasis from a previously unknown appendiceal adenocarcinoma.Presentation with a brain metastasis from a previously undiagnosed primary tumor is not a rare event . This deAlthough brain metastases from all tumors of GI origin, generally a late event in the cancer history , occur in less than 4% of all cases, their incidence is increasing probably because of more effective systemic treatments and prolonged survival. Median survival ranges from 3.8 to 5.4 months. Young age (<65 years old), good Karnofsky performance status, presence of a solitary cerebral lesion, absence of systemic disease at presentation, and type of treatment  seemed as factors associated with prolonged survival , 14. Primary adenocarcinoma of the appendix is a rare malignancy that constitutes less than 0.5% of all GI neoplasms and is generally difficult to diagnose preoperatively , 16. AppOur case report documents that appendiceal malignancy, even if very rare, should be suspected in those cases of cerebral metastasis with a previous unknown primary tumor.


Giant invasive spinal schwannoma is defined as a tumor that extends over two or more vertebral levels, erodes vertebral bodies, and extends into the extraspinal space disrupting myofascial planes. Because of its rarity, there have been few published reports describing clinical features and surgical outcomes, especially in the pediatric patient population.We analyzed the medical record, pathologic findings, and radiographic studies of a 14-year-old Hispanic boy who presented to Texas Children’s Hospital with a three-month history of progressive spastic paraparesis. Preoperative computed tomography and magnetic resonance imaging reports showed a large mass lesion centered at the left T7-8 neural foramen with intra- and extraspinal extension, resulting in severe spinal cord compression and vertebral body erosion, and protrusion into the retropleural space and descending aorta. Our patient underwent a single-stage posterior approach for complete resection of the tumor with reconstruction and stabilization of the vertebral column. The pathological examination was consistent with schwannoma. At the six-month follow-up, our patient had resolution of preoperative symptoms and remains neurologically intact without any radiographic evidence of recurrent tumor.To the best of our knowledge, our case represents the fourth child with giant invasive spinal schwannoma reported in the literature. We describe our case and review the literature to discuss the aggregate clinical features, surgical strategies, and operative outcomes for giant invasive spinal schwannoma in the pediatric age group. Schwannomas are benign tumors originating from Schwann cells, comprising of about 30% of primary intraspinal neoplasms. They moGiant invasive spinal schwannomas are even more rare in the pediatric age group (<=18 years of age). These tumors present as huge masses that extend into the vertebral body and the extraspinal space as reported in case reports and small case series-12. CompA 14-year-old previously healthy Hispanic boy presented to the hospital with a two-month history of progressive worsening mid-back pain, bilateral leg pain, leg weakness, and unsteady gait. On examination, our patient had a spastic paraparesis with obvious signs of myelopathy, including lower extremity hyperreflexia, clonus, upgoing toes on Babinski response, impaired proprioception, and a T10 sensory level.Our patient underwent a workup with a computed tomography (CT) scan of the thoracic spine without contrast with sagittal and coronal reconstructions, and a magnetic resonance imaging (MRI) scan of the thoracic spine with and without gadolinium. The CT scan showed a large left paraspinous soft tissue mass at T7, growing into and filling much of the spinal canal via an expanded and remodeled left T7-8 neural foramen. There was also focal lysis in the posterior T7 vertebral body as well as the left T7 pars, secondary to tumor erosion. The contrast-enhanced MRI scan demonstrated a 4×5×6.4cm heterogenous-enhancing mass with a partial hypointense center. The mass appeared with a classic dumbbell-shaped formation at the left T7-8 neural foramen with severe spinal cord compression Figure .Our patient was placed in a prone position for a lateral extracavitary approach for resecting this large spinal mass. Pre-incision intraoperative neuromonitoring parameters demonstrated no reproducible somatosensory-evoked (SSEPs) and motor-evoked potentials (MEPs) in the lower extremities. A standard subperiosteal dissection was performed from T6 to T8. Bilateral T6, T7, and T8 pedicle screws were placed, except at the left T7 pedicle. A temporary rod was secured on the right for stabilization. A laminectomy was then performed at these levels, and the tumor was observed exiting both the T7-8 neural foramen. Approximately 6cm of the 7th and 8th ribs were resected to complete the lateral extracavitary approach. The mass was mobilized after dissection using a soft tissue plane between the parietal pleura and extracanalicular portion of the tumor. The tumor was debulked and mobilized with the assistance of a Cavitron Ultrasonic Surgical Aspirator (CUSA). Once a surgical cavity was created laterally in the pleural cavity from tumor debulking, we mobilized and swept the portion of the tumor in the spinal canal medial-to-lateral away from the spinal cord into the surgical cavity, completing a gross total resection. The spinal construct was then completed including the use of a structural rib autograft spanning the bony defect created by resection of the facet joint, pars, and pedicle. At the end of the case, SSEPs remained baseline; however, MEPs were now present.Hematoxylin and eosin staining demonstrated predominant Antoni type A pattern with florid formation of Verocay bodies in this spinal tumor. Antoni type B regions were observed as less prominent Figure .Postoperatively, our patient experienced slow improvement of his lower extremity weakness. Our patient was discharged home with a walker six days after surgery. At the six-month follow-up clinical visit, however, he was neurologically intact, and ambulating independently. Postoperative imaging at three months after surgery demonstrated no residual tumor, an evolving fusion mass, and stable posterior fusion construct Figure .et al.[Nerve sheath tumors of the spine are often single, small, benign lesions that are straightforward to remove and are associated with a good postoperative outcome. Giant invasive schwannomas, Type V by the classification of Sridhar et al., differ et al.,17 . The most common symptom in our study was pain (three of three patients), followed by motor weakness (two of three patients), and bowel and bladder symptoms (one of three patients). One of the previous studies reported limited clinical information.Giant invasive spinal schwannomas makes conducting surgery technically challenging because of its growth in all directions and its sheer bulk and volume. They extend longitudinally over two or more levels; laterally into the extraspinal space through a widened and eroded foramen; posteriorly thinning the posterior elements of the vertebral column; and anteriorly eroding the vertebral bodies,6. The aMRI is the primary neurodiagnostic tool in planning the surgical approach and predicting the resectability of giant invasive spinal schwannomas. These tTumor eroding deep pockets into the vertebral bodies should be followed into bone and removed. The bone itself is devoid of tumor and therefore resection of bone for oncologic control is not warranted. Extraspinal extensions of these tumors are usually multilobulated. The surrounding tissues often form a pseudocapsule around the masses. OccasioAlthough we achieved a gross total resection of the giant invasive spinal schwannoma through a single stage and single approach, it may not always be possible to remove the entire tumor in one operative sitting. In these situations, a combined or multi-stage approach may be necessary. The spiThe pathological findings and growth potential for giant invasive spinal schwannomas has not been determined. The majority of patients have typical pathological findings of nerve sheath tumors Figure . Ki-67 iIt is important to plan and predict the need for reconstruction and stabilization of the vertebral column once a significant portion of the tumor has been removed. ErosionThe use of spinal instrumentation does carry significant disadvantages. The most important disadvantage is the casting of the metal artifact on follow-up imaging for tumor surveillance. This is less of a concern in the case of complete tumor resection where tumor recurrence rate is low. However, in cases where partial or subtotal resection is performed, spinal instrumentation may make it easier to determine if there has been small tumor growth on subsequent CTs or MRIs.The results of complete resections of giant invasive spinal schwannomas have been positive,6. Most In the present study, gross total resection was achieved in three of three patients (operative details were not provided for one of the four patients). Of the patients undergoing gross total resection, one patient underwent a second operation for tumor resection as the first operation consisted only of a posterior decompression without any attempt at tumor resection.Giant invasive spinal schwannomas are uncommon tumors and distinct from other schwannomas. The accumulated clinical experience for these tumors in the pediatric age group is virtually nonexistent. We sought to report our own experience in a single case and to review the literature for other pediatric cases. It is clear that because of their local aggressiveness and extension in an omidirectional manner, careful preoperative planning including determination of surgical approach, assessment of resectability, and preparedness to restabilize the vertebral column is important. Complete resection of giant invasive spinal schwannomas is possible with good outcomes; however, they have a tendency to recur, necessitating close follow-up and possible repeat surgeries.Written informed consent was obtained from the patient’s legal guardian for publication of this manuscript and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.CT: Computed tomography; CUSA: Cavitron ultrasonic surgical aspirator; MEP: Motor-evoked potential; MRI: Magnetic resonance imaging; SSEP: Somatosensory-evoked potential.The authors declare that they have no competing interests.SV, PP, and AJ analyzed the patient data and medical records, and were major contributors in writing the manuscript. AMA performed the histological examination of the tumor, and provided pathologic micrographs to support the manuscript. EK and TGL critically reviewed and revised the manuscript. All authors read and approved the final manuscript.


Clear cell sarcoma (CCS), also known as malignant melanoma of soft parts, is a rare type of soft tissue sarcoma which exhibits morphological, immunohistochemical and ultrastructural similarity with malignant melanoma. It is rarely localized in the intestine and the natural history of this tumor is not yet clear.A 49-year-old woman presented with diffuse abdominal colicky pain and vomitus over the previous seven days. An X-ray of the abdomen revealed obstruction of the small intestine. The patient underwent contrast enhanced abdominal computerized tomography (CT), which confirmed the obstruction at the jejunum and an associated circumferential wall thickening extending about 3 cm in length, causing concentric narrowing of the lumen. At laparotomy, a mass was recognized at the level of the jejunum in the small intestine, which caused almost complete obstruction of the lumen. At the point of obstruction, adhered loops of small intestine were found. A segmental small bowel resection was performed with 5 cm clear margins and its respective mesenteric lymph nodes.EWSR1 gene. The patient had an uncomplicated postoperative course and left the hospital seven days after her admission in good general condition. After 20 months of follow-up the patient remains asymptomatic without any clinical or radiological evidence of recurrence.Histological examination of the specimen revealed a tumor (3×3×2cm) with epithelioid cell characteristics and eosinophilic or clear cytoplasm and focal translucent nuclei. Immunohistochemistry was positive for S100, epithelial membrane antigen (EMA) and synaptophysin. The tumor was pankeratin AE1/AE2, GFAP, HMB45 and MART-1/Melan-A negative. Twelve lymph nodes were retrieved and were free of neoplastic infiltration. Cytogenetic examination revealed translocation of the CCS sarcoma can be rarely localized in the jejunum. Due to its morphological similarity to malignant melanoma, cytogenetic examination is necessary for its diagnosis. Wide resection of the tumor and its respective lymph nodes was associated with a 20-month disease free survival in this patient. BRAF mutations[Clear cell sarcoma (CCS) is a rare type of soft tissue sarcoma, originally described by Enzinger in 1965. Howeverutations and in tutations. The tumA 49-year-old female patient presented to the emergency department with a seven-day history of diffuse abdominal colicky pain and continuous vomiting. On clinical examination, the abdomen was distended, exhibiting metallic bowel sounds. An X-ray was performed which indicated obstruction of the small intestine. Computerized tomography showed obstruction at the distal part of the jejunum and eccentric wall thickening, measuring 3 cm.The patient underwent emergency midline laparotomy and a circumferential-eccentric wall thickening of nodular formation was recognized at the level of the jejunum in the small intestine, causing concentric narrowing of the lumen. At the point of obstruction, adhered loops of small intestine were found Figure . PartialEWRS1 gene rearrangement was observed during cytogenetic analysis and 12 out of 12 excised lymph nodes were free from neoplastic infiltration.Pathological examination of the resected small bowel specimen revealed a 3 × 2 × 3 cm tumor. The microscopic examination showed an epithelioid neoplasm which was diffusely infiltrating the bowel wall in sheets and nests. The tumor cells had eosinophilic or clear cytoplasm and vesicular nuclei. In some areas, nuclei with nucleoli were observed. The mitotic rate was approximately eight mitoses per 10 high power fields Figures , focallyThe patient had an uncomplicated post-operative course and left in good general condition after seven days of hospitalization. Twenty months post-operatively the patient remains asymptomatic and has no clinical manifestation of the disease.Clear cell sarcoma is a rare type of malignancy, that shows features of melanocytic differentiation and most commonly affects tendons and aponeuroses of the distal extremities, particularly the foot and ankle (43%) and the knees, wrists and hands. Typically it presents as a slow growing tumor. In rare occasions it primarily affects the gastrointestinal tract. A totalThe presentation of disease consists of intestinal obstruction, anemia or gastrointestinal bleeding. UsuallyThe pathological diagnosis of CCS in the gastrointestinal tract is often difficult, due to the inconsistent expression of melanocytic markers and its unusual site of presentation, requiriIn CCS of tendons and aponeuroses, the commonly accepted management is wide surgical resection of the tumor with or without adjuvant radiotherapy. Metastatic tumors exhibit almost no response to systemic chemotherapy, as shown in a retrospective study of 24 cases. HoweverOverall, GI CCS has an aggressive behavior, with a high incidence of local (lymph node) and distal (most commonly liver) metastasis. In 55% of the cases reported, lymph node metastasis was present at the time of diagnosis and only one case had metastasis to the liver along with regional lymph node metastasis. During the follow-up, liver metastasis developed in 32% of the patients reported, 27% have died and only three patients (14%) showed no evidence of the disease after the resection of the primary lesion. However, the detailed follow-up is not reported in many cases, which possibly leads to underestimation of the morbidity and mortality of the disease. Overall, the behavior is consistent with CCS of tendons and aponeuroses, althougClear cell sarcoma of the gastrointestinal tract is a rare neoplasm with poor prognosis. The diagnosis is based on specific histological, immunohistochemical and genet characteristics. The mainstream treatment is surgical resection of the tumor, while there is no evidence about the effectiveness of adjuvant chemotherapy and radiotherapy.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.CCS: Clear cell sarcoma;CT: Computerized tomography;EMA: epithelial membrane antigen;GI: Gastrointestinal tract;GIST: gastrointestinal stromal tumor;NCCN: National Comprehensive Cancer NetworkThe authors declare that they have no competing interests.KL took part in the care of the patient, manuscript composition and submission. AP and VL collected data, performed the literature research and manuscript composition. MT carried out the pathologic examination and performed the histologic studies. GC took part in the care of the patients, and the coordination and final editing of the manuscript. All authors read and approved the final manuscript.


The sign of Leser-Trélat is a rare paraneoplastic phenomenon marked by accelerated onset of multiple seborrheic keratoses. The occurrence of the sign often points towards underlying visceral malignancies which in a majority are adenocarcinomas of the gastrointestinal tract. We report this case of a 65-year-old man who presented with sign of Leser-Trélat and was diagnosed with poorly differentiated squamous cell cancer of the esophagus. To our knowledge this is only the second such reported association of Leser-Trélat sign with squamous cell cancer of esophagus. The sign of Leser-Trélat is a misnomer as both Edmund Leser and Ulysse Trélat described skin lesions unrelated (senile angiomas) to seborrheic keratoses , 2. It wA 65-year-old Hispanic man presented to the clinic with complaints of progressively worsening dysphagia and unintentional weight loss of 30 pounds over the preceding 2 months. Patient reported dysphagia to both solid as well as liquid food. Patient also complained of multiple worsening (both in size and in number) dark colored skin lesions on his neck and his back. His medical comorbidities included well controlled bronchial asthma and vitamin B12 deficiency. The patient admitted to chronic heavy smoking for almost 40 years. Physical examination revealed a hemodynamically stable, cachectic man (BMI: 19.4) with multiple hyperpigmented, well-demarcated and raised lesions with “stuck-on” appearance on both sides of the neck  and the Initial set of laboratory were remarkable only for normocytic, normochromic anemia (hemoglobin of 10.1 g/dL). He underwent a colonoscopy and esophagogastroduodenoscopy (EGD) for further evaluation of unintentional weight loss and dysphagia. Colonoscopy revealed good bowel preparation with a single 3 mm hyperplastic transverse colon polyp. EGD revealed a noncircumferential, partially obstructing mass in the lower third of the esophagus . BiopsiePatient underwent surgical gastrostomy for nutritional support. Patient subsequently was started on radiation therapy and chemotherapy with weekly Paclitaxel and Carboplatin regimen. Patient underwent a repeat EGD, upon completion of 8 cycles of Paclitaxel and Carboplatin regimen that revealed significant improvement in size of the esophageal mass. However, the seborrheic keratoses did not regress in parallel.α [In spite of various arguments put forth against considering the sign of Leser-Trélat to be a true paraneoplastic phenomenon, Curth  providedα , insulinα , and epiα . The varα . Regressα , 12.Even as the sign of Leser-Trélat is most commonly associated with carcinomas of gastrointestinal tract, its association with squamous cell cancer of esophagus is exceedingly rare. To our knowledge this is only the second such association reported in the literature . The mosWe report this case of sign of Leser-Trélat associated with esophageal squamous cell carcinoma to highlight that an otherwise benign, asymptomatic and often ignored presentation of eruptive seborrheic keratoses could be an ominous sign that should prompt elicitation of detailed history and thorough physical examination. Any alarm symptoms or signs should be followed up by correlative testing.


Case 1: A 50-year-old woman presents for excision of lesion along right nasolabial fold, which has been present for 2 years and has been increasing in size. Patient describes the lesion as itchy and denies pain, bleeding, or other symptoms.Case 2: A 47-year-old man presents for excision of lesion along right nasolabial fold, which has been present for 1.5 years and has been increasing in size. Patient describes the lesion as itchy and occasional bleeding. He denies pain or other symptoms.Describe the lesion in each picture.What are the differential diagnoses?State the various treatment modalities of these lesions.What reconstructive options are available?There is a broad differential diagnoses for lesions in the nasal region, which includes traumatic injury to the skin (sunburns), benign conditions , precancerous (actinic keratosis) and cancerous  lesions. A full patient history is important to narrow the diagnosis and biopsy is critical to identify potential neoplasia.In the 2 cases described, biopsy identified both lesions as BCC. Basal cell carcinoma is the most prevalent skin cancer and is commonly found in sun-exposed areas including the head and neck. Ultraviolet light causes formation of thymine dimers and depression of the local immune system, allowing pluripotent cells in the basal layer of the epidermis to proliferate uncontrollably.Once diagnosed, the goal of treatment is eradication of the tumor to prohibit further malignant proliferation. Surgical treatment options for BCC include curettage and electrodesiccation, Mohs procedure, and excision. Factors such as tumor size and location, patient age and ability to tolerate surgery, and expense must be considered. Curettage and electrodesiccation is quick and inexpensive with high cure rates. However, it is a blind technique and this lack of margin control limits its use to nonaggressive and superficial BCC. Mohs surgery examines 100% of surgical margins to provide the best long-term cure rates; however, it is expensive and time-consuming when compared to other techniques. Surgical excision removes the clinically apparent tumor and a sufficient margin to achieve high cure rates. For patients who have multiple comorbidities or cannot tolerate anesthesia, cryotherapy and radiation therapy are alternative treatment options.In determining the best surgical margin for BCC, Gulleth et al conducted a meta-analysis of the literature and compared average recurrence rates and the relative risk of recurrence in margins 1- to 4-mm versus a 5-mm resection. Although a larger surgical margin lowers the relative risk of recurrence, they found that achieving a clear surgical margin does not correlate with lower recurrence risk. For surgeons who desire a minimum 95 percent cure rate, the data indicates that a 3-mm surgical margin may be safely used for BCC lesions 2 cm or smaller.The 2 modalities considered for reconstructive management in these patients are full-thickness skin grafts (FTSG) and transposition flaps. FTSG are a single-stage procedure, they preserve the anatomy and tend to have smaller incision lines. Transposition flaps like the V-Y advancement flap are alternatives to FTSG and take little time, are not risky, and recover faster. However, planning must be meticulous or a bad outcome will result. Variables such as the size of the defect, its location, the quality of skin, and the surgical preference are used to determine the best treatment for each individual patient.


Mucinous cystadenoma of the liver is a rare (less than 5%) neoplasm. This condition is more common in young women and accounts for non-specific symptoms. Cyst adenomas commonly affect the intrahepatic system (90%) and are rarely found in the extrahepatic biliary system or affecting both the systems.A 39-year-old Sinhalese woman presented with features of obstructive jaundice and was found to have a biliary neoplasm on imaging. In the absence of a definitive diagnosis despite extensive imaging she underwent preoperative endoscopic biliary drainage followed by a left hemihepatectomy with Roux-en-Y hepaticojejunostomy. A pathological examination of the specimen revealed an obstruction of the bile duct caused by a biliary mucinous cystadenoma affecting both the intrahepatic and extrahepatic systems.Biliary mucinous cystadenoma rarely present with obstructive jaundice affecting both intrahepatic and extrahepatic ducts. Exhaustive investigation might not help in the diagnosis and may need to be treated based on clinical judgment. The definitive treatment modality is surgery due to its malignant potential. The operative procedure is technically demanding and is best performed at specialist centers to minimize complications. Cystadenomas arising from the biliary epithelium account for less than 5% of the cystic neoplasms of the liver. ClinicaA 39-year-old Sinhalese woman presented with obstructive jaundice of 3 months’ duration. She had deeply icteric sclera with evidence of pruritus. An abdominal examination revealed mild hepatomegaly. Serum bilirubin, alkaline phosphatase and gamma-glutamyl transferase levels were significantly elevated while the transaminases were moderately high. An ultrasound examination was suggestive of a cystic lesion in segment IV of her liver with dilated intrahepatic ducts. A triphasic computed tomography (CT) scan revealed a non-enhancing cystic lesion on segment IV with intrahepatic duct dilatation. A subsequent magnetic resonance imaging (MRI) scan of her liver and magnetic resonance cholangiopancreatogram (MRCP) confirmed the cystic lesion in her liver and a mass lesion occupying the common hepatic duct and proximal common bile duct up to the level of her duodenum Figure . Her serExamination of the specimen revealed a cystic lesion located in segment IV of her liver with extension of a solid mass along the duct of segment IV, up to her common bile duct completely obstructing the extrahepatic biliary system Figure . A histoShe had an uneventful recovery. She was symptom free at her 3-month postoperative follow-up visit with no clinical or ultrasonic evidence of recurrence.Biliary cystadenomas are rare benign tumors with a potential for malignant change. Of the Tumor markers are nonspecific, although CA 19–9 levels are known to be high. Intracystic fluid CA 19–9 levels are particularly elevated in cystadenomas. This patient had a serum CA 19–9 level of over 1000U/mL .et al. studying radiological features of 25 cysts on CT images concluded that upstream biliary dilatation, transient hepatic attenuation difference, location in the left lobe and the presence of fewer than three cysts to be in favor of a neoplasm rather than a simple cyst[An ultrasound scan and triphasic CT scan of the abdomen are considered adequate to arrive at the diagnosis in most cases. MRI and MRCP were performed in this patient because of atypical presentation with obstructive jaundice. On ultrasound scanning, the hepatic cystadenomas appear as anechoic lesions with septations. On a CT scan, the tumor appears as low-density areas with focal enhancement after contrast administration. The septa and the mural nodules may be visible. However, these imaging modalities may not distinguish benign lesions from malignant type but malignant transformation can be suspected by thickened cyst wall, calcification, and papillary projections within the separations. Kim et ple cyst. This paet al.[The histopathological evaluation of the cyst wall is of importance to differentiate the mucinous cystadenoma from other types of liver cysts and to identify malignant transformation. Other cyst types needing differentiation are the simple cyst, cystic hamartomas and the recently described biliary intraductal papillary neoplasm (IPN). Particular characteristics of the mucinous cystadenoma are the single cuboidal epithelium lining and ovarian-type subepithelial stroma. Both thet al. have obsRadical surgical excision of the tumor with a 2cm margin is the accepted treatment of choice for mucinous cyst adenoma,11. LessBiliary cystadenomas rarely present with features of obstructive jaundice and pose a diagnostic challenge. Availability of imaging modalities may not help to distinguish these lesions from cholangiocarcinomas. They are best treated radically as they have a definite potential to transform into malignant tumors. Preoperative endoscopic biliary drainage was safely performed in this situation but more evidence is needed before it is incorporated into routine practice, hence a selective approach is suitable. Surgical resection is technically demanding and is best performed at specialized hepatobiliary centers.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.CA: Carbohydrate antigen; CT: Computed tomography; ERCP: Endoscopic retrograde cholangiopancreatogram; IPN: Intraductal papillary neoplasm; MRCP: Magnetic resonance cholangiopancreatogram; MRI: Magnetic resonance imaging.The authors declare that they have no competing interests.PCC was involved in acquiring patient data, literature survey on the subject, patient management and preparing the manuscript. CL and SRW were responsible for carrying out the investigative procedures and surgery on the patient. KID and SRW were also actively involved in preparing the manuscript and critical appraisal. All authors read and approved the final manuscript.


Introduction. In patients with extra-adrenal malignancy, an adrenal mass necessitates investigating the possibility of metastatic tumor. Curable adrenal metastasis are considered as a rare event. Case report. A 52-year-old male suffering from lower esophageal adenocarcinoma with a solitary left adrenal metastasis is presented herein, who underwent concomitant transhiatal esophagectomy and left adrenalectomy. The patient remains disease-free 18 months later. Discussion. Adrenal metastases mostly occur in patients with lung, kidney, breast, and gastrointestinal carcinomas. Primary esophageal adenocarcinoma gives adrenal metastatic deposits according to autopsy series with an incidence of about 3%–12%. When no other evidence of metastatic disease in cancer patients exists, several authors advocate adrenalectomy with curative intent. Isolated cases of long-term survival after resection of solitary adrenal metastasis from esophageal adenocarcinoma, like in our case, have been reported only as case reports. Conclusion. This study concludes that surgical resection may result in survival benefit in selected patients with solitary adrenal metastasis from esophageal adenocarcinoma. In patients with extra-adrenal malignancy, staging imaging modalities frequently reveal adrenal masses and require exclusion of the possibility of metastatic tumor spread . AdrenalA 52-year-old male presented complaining of dysphagia in both solid food and liquids for the last fifteen days. Esophagogastroduodenoscopy (EGD) revealed a solid mass narrowing the esophageal lumen on the lower third of the esophagus . HistopaAn adrenal mass lesion can represent multiple pathologic entities, benign or malignant. Most of these lesions are simple adenomas or secondary metastatic tumors . AdrenalThe management of a solitary adrenal metastasis in cancer patients can present as a surgical dilemma. This study concludes that surgical resection may result in survival benefit in selected patients with solitary adrenal metastasis from esophageal adenocarcinoma and should be considered as a therapeutic option.


Vernix caseosa peritonitis (VCP) is a rare and poorly recognised condition resulting from a sustained foreign body reaction to the vernix caseosa of the baby. This case-based review aims to highlight its importance for any medical team managing patients with peritonitis who have undergone a recent Caesarean section.A 31-year-old woman presented 5 weeks after a Caesarean section with symptoms and signs of peritonitis.Laparotomy and peritoneal lavage is the mainstay of treatment for VCP. Knowledge of the condition may stop inadvertent resection of normal intra-abdominal organs. Greater awareness of VCP is required to ensure earlier recognition as patients can recover well following timely operative intervention. Vernix caseosa is a thick white paste that is present on foetal skin from the third trimester of pregnancy until shortly after birth.VCP is a rare condition that affects women post-Caesarean section following spillage of amniotic fluid and vernix caseosa into the peritoneal cavity. Vernix caseosa can result in a profound systemic inflammatory response that necessitates maternal laparotomy and may lead to erroneous resection of intra-abdominal organs. Diagnosis is often difficult due to a lack of awareness of the condition and may only be made following histological examination. Confusion regarding diagnosis can result in considerable anxiety for both the patient and surgeon in the ongoing management of the condition.We present a case report of VCP in a 30-year-old woman 5 weeks after a Caesarean section.9/1.A 30-year-old primigravida woman delivered a healthy baby boy by lower segment Caesarean section (LSCS) at 40 weeks after conversion from natural delivery due to failure to progress. She had an unremarkable antenatal period and no significant medical history. Five weeks following the LSCS, she presented with a 48-hour history of generalised abdominal pain, vomiting and diarrhoea, and was admitted with a provisional diagnosis of gastroenteritis under the care of the medical team. Clinical examination revealed a systemic inflammatory response syndrome (SIRS) with a pulse rate of 150bpm, blood pressure of 97/55mmHg and temperature of 39.1ºC. Abdominal examination demonstrated a soft abdomen with generalised tenderness. The LSCS wound looked healthy. The C-reactive protein level was 481mg/l with a neutropaenia of 2.2 × 109/l. Stool, urine and blood cultures were all negative.Intravenous fluid and antibiotics were administered. Computed tomography (CT) of the abdomen and pelvis on day 2 demonstrated some free fluid. The patient was transferred to the intensive care unit (ICU) and was prescribed granulocyte colony stimulating factor, which increased her neutrophil count to 41.2 × 10The patient deteriorated further with increased pain, a distended abdomen and signs of peritonitis. Repeat CT demonstrated an increased volume of intra-abdominal free fluid. An urgent laparotomy was performed, which revealed a multiloculated fluid collection in the abdomen and pelvis that was not malodorous. The uterus was intact. There was widespread inflammatory change throughout the peritoneal cavity with large volumes of fibrinous material. Appendicitis was presumed and an appendicectomy and extensive peritoneal lavage performed. Two large drains were sited, in the right paracolic gutter and the pelvis. The patient improved post-operatively with a concomitant decrease in inflammatory markers.Histology of the appendix revealed acute fibrinous serositis and material taken from the abdominal cavity demonstrated degenerate anucleate squamous cells in keeping with VCP . Furtheret alThe literature base for VCP is limited  and, to Our patient presented to hospital five weeks following her LSCS, which is the longest period currently described in the literature. Diagnosis was made after seven days, multiple radiographic tests, a period on the ICU, and following laparotomy and histological confirmation. This highlights the diagnostic dilemma with VCP.A study published in 2011 reports that VCP could be diagnosed with image guided biopsyFollowing our experience with VCP, we recommend laparotomy and peritoneal lavage as the mainstay of treatment, with intravenous antibiotic cover and critical care support if required. We note that steroid therapy has been used successfully in some cases.Although the condition is not often described in medical textbooks,This case highlights the lack of awareness in the medical community of VCP. In spite of its rarity, VCP represents serious post-Caesarean section morbidity and may require urgent surgical management. Diagnosis requires close involvement with the histopathologist. Management should entail rigorous peritoneal lavage and placement of intra-abdominal drains to monitor for early recurrence. It is unknown whether VCP can present later than five weeks post-partum but consideration of VCP as a diagnosis is important in any woman presenting with an acute abdomen following a recent Caesarean section.


Pancreatic adenocarcinoma is the 5th leading cause of cancer-related death in Western countries and insulinomas are rare endocrine neoplasms of the pancreas. The concurrent appearance of pancreatic adenocarcinoma and insulinoma is very rare and to the best of our knowledge has never been reported again. Herein, we present such an occurrence in a 74-year-old man. Resection of a mass in the uncinate process of the pancreas revealed pancreatic adenocarcinoma with severe desmoplastic reaction. Two years later, due to symptomatology persistence the patient was re-examined and a new 2cm mass in the uncinate process was found leading to surgery, which demonstrated a 2cm endocrine islet-cell tumor. Establishing a diagnosis in patients with insulinoma is difficult and the imaging studies still have low sensitivity and specificity except for intra-operative ultrasonography, which is the most accurate method detecting 90% of these lesions. Pancreatic endocrine neoplasms are rare tumours with a reported incidence of four cases per million patients per year . Of thesA 74-year-old man was admitted to our hospital, suffering for the last 2 years from hypoglycaemic attacks. Laboratory tests showed fasting glucose level below 50mg/dl and symptoms of hypoglycaemia such as tachycardia, sweating, confusion and light-headedness. The correction of the above when glucose was administered was significant, so the Whipple's triad was present. Plasma-insulin level, measured through the extended 72-hours fasting test was found 12mIU/ml and C-peptide level was also elevated, 4.3ng/ml. Tumour markers were within normal range apart from Ca 19-9 which was 5IU/ml.Abdominal ultrasonography (US) did not reveal any lesion, but a contrast enhanced CT scan demonstrated a 1.5cm solid mass in the uncinate process of the pancreas Figure . We estiSerial evaluation of Ca 19-9, at 3-month intervals, during the following two years, was found within normal range. Due to persistence of hypoglycaemic symptoms, successive abdominal CT scans completed the follow-up  but theyThe main clinical symptom in insulinoma patients is the inability to suppress insulin secretion in the presence of hypoglycaemia, resulting in neuroglycopenia and adrenergic manifestations like headache, confusion, visual troubles, shivering, irritability and palpitations . HoweverIn our case, palpation of the lesion in the uncinate process during the first operation thought to be the mass, which had been demonstrated on the preoperative abdominal CT. Unfortunately, we missed the 1.5cm insulinoma and the resected area revealed a 1mm pancreatic adenocarcinoma with severe desmoplastic reaction in the surrounding tissue, which when palpated obviously misled us to believe that it corresponded to the insulinoma. The patient's symptoms pertained and serial CT scans revealed the 2cm insulinoma which was successfully treated with a Whipple's procedure.Mixed pancreatic tumours, either collision or composite ones, from endocrine and exocrine cells have been reported in the literature , as wellThe coexistence of pancreatic adenocarcinoma and insulinoma is very rare and has never been reported before. Clinical symptoms should be evaluated carefully and since imaging modalities have low sensitivity and specificity in detecting small endocrine neoplasms, sequential imaging studies and intraoperative US can prove very helpful.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.PA participated in the surgical procedure, conceived and designed the study, and wrote the manuscript. GP analysed the data and drafted critically the manuscript. DD participated in the surgical procedure, acquired the data and helped in writing the manuscript. GM helped in the acquisition and interpretation of data, and he drafted the manuscript. EK performed the appropriate histological analysis of the surgical specimens and provided histological sections as figures for the manuscript. DV carried out the surgical procedure, participated in designing the study and finally revised the manuscript for submission. All authors read and approved the final manuscript.


Submucosal lipomas of the large bowel are uncommon. Occasionally, they occur in the rectum and may cause aspecific symptoms; presentation with rectal prolapse is very unusual and may lead to a misdiagnosis of simple mucosal prolapse. The paper describes an additional case of a prolapsing rectal mass that led to diagnosis and surgical treatment of a rectal lipoma under local anesthesia. A 80-year-old man presented with a recent onset of constipation, anal discomfort, and anal incontinence.Several months ago, he experienced a sensation of something passing through the anus at defecation, that he manually reinserted, accompanied by tenesmus and rectal bleeding, for which he had a diagnosis of “hemorrhoids”.These symptoms worsened in the following months, since the mass began to prolapse independently of defecation, became painful when standing or walking, made defecation obstructed, and caused anal incontinence, for which he was referred with a presumptive diagnosis of neoplasia. Abdominal examination was unremarkable. Inspection of anal region revealed a large, soft, ulcerated mass protruding through the anus that was suspected for a submucosal neoplasia. The mass was easily reducible but prolapsed again.At operation, the mass was pulled through the anal canal, and it was noted that it arises in the posterior wall of the rectum, 3 centimetres above the dentate line, where it developed a pseudostalk, presumably as a result of the repeated prolapses. The mucosa above the mass was injected with lidocaine and incised. The mass was sharply dissected and removed. The macroscopic appearance was that of a lipoma. The diameter was 9 centimetres. The mucosal edges were reapproximated by an absorbable running suture.Histological examination confirmed the diagnosis of lipoma.Lipomas of the large intestine are relatively uncommon in clinical practice, although they are considered to be the benign tumours that occur most frequently, adenomas excluded, and the commonest nonepithelial tumours.Most affected patients are in the 5th to 7th decades of life. Some authors have reported a female predominance while others found a nearly equal sex incidence . In geneSymptoms, that include bleeding, constipation, changing bowel habits, abdominal pain, intestinal obstruction, or intussusception of the mass –7, are mSpontaneous expulsion of a sigmoid lipoma has been reported .Lesions are sessile or polypoid and are submucosal, in about 90% of cases, or subserosal.In size, the tumours range from a few millimetres to several centimetres   and not The most common site of origin is the right colon , 9. TherHaller and Roberts reviewed 29 lipomas of the large bowel in 20 patients, none of which was in the rectum [Michowitz et al., found only one lipoma of the rectosigmoid (4.54%) in his series of 22 cases .In an 18-year study, Rogy et al. reported 17 patients with lipomas of the large bowel, and only three out of 21 were in the rectum .Bozza et al. reported 11 patients with large bowel lipomas, all located proximal to the sigmoid colon . The prolapse of a rectal lipoma through the anus is a rare event, and a few cases are reported in the literature , 14. Taylor and Wolff, in a review of the Mayo clinic experience of 91 surgically managed colonic lipomas from 1976 to 1985, report no rectal location .Ryan et al., in a review of the surgical pathology files, over a 50-year period, found 13 cases of colonic lipomas, none of these were in the rectum .Creasy et al. identified 5 patients with symptomatic lipoma of the large bowel, searching the computerized histopathologic records of the Leicester General Hospital and Leicester Royal Infirmary, in a 11-year period, located, respectively in proximal colon (2), sigmoid colon (2), and rectum (1) [The patient with the rectal lipoma was a 35-year-old female presented as an emergency with lower abdominal pain and prolapsed rectal polyp, 6 centimetres in diameter , in the ileocaecal region (4), and in the colon (3); the more distal lipoma was found in the sigmoid colon .


Ancient schwannoma is a rare variant of neural tumors though rarely seen in the thorax. The combination with coronary artery diseases is also rare. Here we describe a 66 year-old male who had undergone one-stage combined surgery for thoracic ancient schwannomas removal and coronary artery disease. The masses were, respectively, 13 cm in the middle mediastinum and 5 cm in diameter originating from the intercostal nerve. The tumors were successfully removed using sternotomy, and then a coronary artery bypass grafting was performed. Here we discuss this rare tumor in relation to the relevant literature. Schwannomas are neurogenic tumors originating from Schwann cells of the neural sheath. Ancient schwannoma is a rare type of schwannoma that tends to grow slowly. The term “ancient” is proposed to describe neural tumors with long duration showing degenerative changes. Schwannomas are usually benign tumors, but the marked nuclear atypia of the tumor often leads to erroneous diagnosis of malignancy. Schwannomas frequently originate from the extremities, head and neck, and are most often localized in deep sites such as the retroperitoneum. They are rare in the thorax.A 66 year-old male patient had been followed for nearly two years with a mediastinal mass. Two years ago a mass was observed near the left cardiac margin measuring 6.5 × 5.7 cm in a modified left parasternal view of the transthoracic using echocardiography . FurtherIn preoperative evaluation, we considered it possible that the mass dwelling on the aortic arch may make it impossible for proximal anastomoses of coronary bypass. In order to avoid this complication, we decided to first remove the mass, then perform coronary artery bypass grafting using sternotomy, in a one-stage combined operation. The chest was opened by sternotomy, and a huge encapsulated mass was observed dwelling the aortic arch and the left pulmonary artery with a proximal extension to the ascending aorta . After pThe gross appearances of these two masses were alike. They were reddish, bright, encapsulated masses measuring 13 cm and 5 cm in diameter, respectively. The cut surfaces had a bright, tan/yellow, gelatinous appearance, and a small solid area was observed in the larger one Figures  and 7.On histological examination degenerative changes and atypical nuclear features were noted, but a mitotic figure was lacking. Immunohistochemical analysis was positive for S-100 protein Figures  and 9.The patient was discharged on the sixth day after the operation with a slightly elevated left diaphragm. Voice hoarseness was observed on control examination. On further control examinations, the elevation of the diaphragm had gone back to normal and the voice had improved. Whole body examination to exclude the possibility of Von Recklinghausen's neurofibromatosis revealed no additional tumors. The patient recovered fully one year after the operation; recurrence and metastasis were not observed.Ancient schwannomas are encapsulated tumors with long duration and a benign nature, showing degenerative changes. Malignant transformation is rare. Few cases of thoracic ancient schwannoma have been reported in the literature –5.These tumors tend to develop slowly and seem to be symptomless until they reach a sufficient size to compress adjacent structures. They may be detected incidentally on routine roentgenograms. Our patient was asymptomatic until cardiac complaints began, and a paracardiac mass was detected by transthoracic echocardiography.Schwannomas usually arise in the base of the spinal nerves but sometimes involve the thoracic nerves. They are often single lesions, but multiple tumors along a nerve may also occur. They may occasionally be associated with bone, skin, and central nervous system lesions (Von Recklinghausen's neurofibromatosis). Malign transformation risk is higher in patients with Von Recklinghausen's disease, but a solitary neurofibroma rarely tends to be malignant , 5. The radiological features of ancient schwannomas have not been well described due to their rarity . Long-teSome authors suggest that diagnosis of ancient schwannoma be considered when a patient presents with a hypervascular soft tissue mass containing amorphous calcification on plain graph and cystic areas on magnetic resonance imaging. They suggest that soft tissue calcification which is visible in a plain graph may be a characteristic feature of an ancient schwannoma . As someMicroscopically, schwannomas show a biphasic pattern with areas of highly ordered cellularity (Antoni type A) and with other less cellular areas where a copious myxoid matrix predominates (Antoni type B). Ancient schwannoma describes a tumor that has undergone degenerative changes with relative loss of Antoni type A areas and atypical nuclear features. The most significant histological features of these tumors are the presence of a high degree of nuclear atypia. Atypical cells show large, polymorphic, hyperchromatic, and often multilobed nuclei but lack mitotic figures.Preoperative fine needle biopsy can be performed but an exact diagnosis may not be possible due to limited cellularity and the possibility of a mistaken diagnosis of malignant neoplasm due to degenerative histological changes . Surgica


Introduction. An antrolith is a calcified mass within the maxillary sinus. The origin of the nidus of calcification may be extrinsic (foreign body in sinus) or intrinsic . Most antroliths are small and asymptomatic. Larger ones may present as sinusitis with symptoms like pain and discharge. Case Report. We report a case of a 47-year-old lady who presented with heaviness on the left side of the face and loosening of the left 2nd molar tooth since two months. CT scan of the osteomeatal complex and paranasal sinuses showed an opacification of bilateral maxillary sinus and an amorphous area of bone density in the left maxillary sinus. Because of the size of the mass, benign neoplasms were considered in the differential diagnosis. During an endoscopic sinus surgery, it was found to be an antrolith, which was successfully managed by antrostomy and Caldwell-Luc Surgery. Discussion. Antrolith is a rare condition. Rhinoliths are known to invade into the maxillary antrum, but a localised lesion in the antrum is very unusual. A case of an isolated antrolith is presented for its rarity and for differential diagnosis of localised antral disease. Conclusion. Antrolith should be considered as differential diagnosis of unilateral radio-opaque paranasal sinus lesions. Antrolith is a calcified mass that occurs in the maxillary sinus. Stones arising in the antral cavities are uncommon, and their development is similar to that of a sialolith. They may form around a nidus or a concentrated mucus, which continues to grow because of the precipitation of calcium salts in concentric layers , 2. SmalA 47-year-old lady presented to us with heaviness on the left side of the face since two months and loosening of the left 2nd molar tooth of recent onset. She had also noticed a foul smelling purulent nasal discharge from the left nostril since the past week. Her past history records revealed that she had undergone Caldwell-Luc surgery on the left side way back in the year 1984 for the removal of unilateral extensive polypoid disease. The family and personal history were not significant. Her general physical examination appeared normal without any obvious deformities or abnormalities. Oral cavity examination revealed the presence of a mobile upper 2nd molar tooth on the left side along with the presence of purulent discharge beside the teeth suggestive of an oroantral fistula. Posterior pharyngeal wall showed the presence of a thick postnasal drip. Her nasal cavity and paranasal sinus examination were essentially normal but for a mid-level deviation in the septum and tenderness elicited on the skin overlying the left maxillary sinus. All of her other systems seemed to be normal clinically. So with a diagnosis of recurrent maxillary sinusitis and an oroantral fistula in mind, we proceeded with plain computed tomography scan of the osteomeatal complex and the paranasal sinus, which showed opacification of bilateral maxillary sinus and amorphous area of bone density in the left maxillary sinus suggestive of osteoma . KeepingIn order to alleviate the symptoms and reach upon a definitive diagnosis, we planned an endoscopic sinus surgery. A wide antrostomy was performed which revealed a brownish looking hard gritty mass surrounded by pus and polypoid mucosa . Upon prklebsiella spp.resistant to ampicillin and sensitive to most of the other parenteral antibiotics. The reporting on the intraoperative specimen turned out be a diagnosis of exclusion, since the possibilities of osteoma, malignancy, rhinoscleroma, and fungal concretions were ruled out after suitable decalcification procedures and Periodic acid-Schiff staining techniques. We were thus left a freely lying calcareous mass which was irregular in shape and not attached to any wall of the maxillary sinus, and thus logically we concluded it to be a sinolith/rhinolith in the left maxillary sinus, rephrased as an antrolith. This was confirmed by the effective decalcification of the mass which left behind only the organic matter.Culture and sensitivity of the pus from the left maxillary sinus revealed growth of Antroliths are calcified bodies within the antral cavity. The term rhinolith was first coined in 1845 to describe a partially or completely encrusted foreign body in the nose , 3. The The antral foreign body constitutes the central core of the antrolith. The central core is usually of endogenous and less commonly of exogenous origin. If the central core arises around normal or abnormal body tissues, it is of endogenous origin. These include tooth and bony fragments, blood, pus, mucus, and fungi . On the  Patients with antrolith may be asymptomatic and may be incidentally discovered on routine radiological examination . HoweverAspergillus fumigatus (noninvasive mycetoma) [Radiographically, a dense, irregular yet well-defined mass can be identified in the antrum. They can be seen on panoramic, periapical, and Waters' radiographs in addition to computed tomograms . Focal aycetoma) . Antroliycetoma) , 8. The In our case, the predisposing factor would have been bony chips left behind following the past Caldwell-Luc surgery. Thus, we suggest the thorough irrigation of sinus cavity following endoscopic sinus surgery to prevent future formation of antrolith around any endogenous nidus.Although rare, antrolith should be considered as a differential diagnosis of radiopacity in the paranasal sinus lesion. An endoscopic sinus surgery combined with Caldwell-Luc operation is a reliable procedure for the removal of a large antrolith in the maxillary sinus, as it provides better exposure, ventilation, and drainage of the sinuses.


Neoplasms of the fallopian tube are extremely uncommon. In addition, the incidence of a mature teratoma of the fallopian tube with incomplete uterine mediastinum is extremely low. In the current case report, we present a case of mature cystic teratoma of the fallopian tube with incomplete uterine mediastinum in a 23-year-old female. This mass was noted on computed tomography (CT) scan and sonographic examination. The patient underwent left salpingectomy and uterine septum incision during surgery. One year later, the individual became pregnant. Neoplasms of the fallopian tube are the least common tumors of the female reproductive system. To date, mature teratoma of the fallopian tube associated with incomplete uterine mediastinum has not been reported and ∼60 cases of mature teratoma of the fallopian tube have been reported worldwide. None of the reported cases were diagnosed preoperatively. The pathogenesis of teratoma of the fallopian tube remains poorly understood. Tumors are accidentally discovered and confirmed by pelvic surgery, as a result of diagnosis of uterine fibroids, ovarian cysts and cesarean sections. It has been hypothesized that teratomas originate from the germ cells, as teratomas are found most frequently in the gonads. The karyotype of all benign teratomas is 46,XX. Surgery is used to treat teratomas and the prognosis of this disease is generally good –5. In thgravida 0, para 0) who had been married for two years was admitted to The Second Xiangya Hospital of Central South University  with fertility issues. The patient reported intermittent lower abdominal pain for 8 months. The individual’s menstrual cycle was regular. Pelvic examination revealed a stationary cystic mass of ∼8×3 cm in the left adnexal region; the right adnexa and the uterus were normal. The patient’s family history was negative for any hereditary diseases. Serum concentrations of C12 were within the normal limits. Ultrasound examination revealed that the endometrium was unclear, and a cystic mass of ∼8×4 cm to the right of hypogastic region was observed. The mass contained foci of calcification of ∼3×2 cm  was observed at the bottom of the uterus. The left fallopian tube appeared to be distended by ∼8×3 cm, and contained cream-colored sebaceous material and hair. The left ovary and the right adnexa were normal. The patient subsequently underwent left salpingectomy and uterine septum incision. The post-operative recovesry was uneventful. The ampullary portion of the left fallopian tube was histologically diagnosed as mature cystic teratoma  and 5.Tubal teratoma may be associated with other neoplasms ,7, strumIn conclusion, benign teratomas commonly occur in the ovaries, but are rarely found in the fallopian tubes. Although the present case was a cystic teratoma, immature tissues were not identified by microscopic examination of the specimens by several pathologists. Therefore, a diagnosis of a benign mature cystic teratoma originating in the fallopian tube was reported for this patient.


Duplication cysts (DCs) of alimentary tract are rare congenital malformations. They are firmly attached to the wall of the gastrointestinal tract and they are supplied by surrounding mesenteric blood vessels. More than 80% of cases occur before the age of two years and only a minority of cases present in adulthood. “Completely isolated duplication” of the alimentary tract is an extremely rare variety of gastrointestinal duplications. They have gastrointestinal epithelial and wall characteristics without an anatomic association with the alimentary tract. Their main characteristic is that they have their own blood supply. A 20-year-old male was admitted to our department with symptoms persisting for a period of one week prior to admission, which included abdominal pain, fever, and a palpable abdominal mass. CT revealed an unexplained intraperitoneal abscess. This case represents a rare clinical example of infected isolated duplication cyst managed with percutaneous drainage and surgical excision of the cyst 3 weeks later. To the best of our knowledge, this is the first reported case to use this approach. Gastrointestinal duplications (GDs) are rare congenital malformations that may vary greatly in presentation, size, location, and symptoms. They are either cystic or tubular. Cystic duplications rarely communicate with the intestinal lumen. In contrast, tubular duplications usually communicate with the intestinal lumen. In almost half of the cases, duplication cysts are associated with other malformations, mainly located in the vertebrae and genitourinary track. They share a common blood supply with the adjacent bowel wall and they tend to be located on the mesenteric aspect of the alimentary canal.GDs originate anywhere along the alimentary tract from the tongue to the anus, with small bowel and particularly ileum being the most common location for these entities –3. The cMore than 80% of cases present before the age of two years , 2, 4. CCompletely isolated duplication cyst is an extremely rare variety of gastrointestinal duplications and very few cases have been reported. They do not communicate with the normal bowel and their main characteristic is the fact that they have their own blood supply –7.Herein we report an adult male with an infected completely isolated duplication cyst.9/L, C-reactive protein 40 mg/dL, whereas all other findings were normal.A 20-year-old male was admitted to our department with one-week history of abdominal pain and fever. The previous medical history was unremarkable. His body temperature was 38.7°C and physical examination revealed a palpable, painful mass occupying the right abdomen. Routine laboratory studies showed elevated WBC to be 16500 × 10CT scan revealed a cystic mass measuring 25 × 10 × 7 cm, occupying the right abdomen, and extending from the lower surface of the right lobe of the liver to the pelvis. The cyst was laterally of ascending colon. The wall of the cyst was thickened and a small amount of free peritoneal fluid was presented. An incidental finding was the existence of horseshoe kidney . A widely spectrum antibiotic (Piperacillin/tazobactam) was administered intravenously and a CT-guided percutaneous drainage of the cyst was decided. 1200 mL pus was aspirated and two drainage tubes were left in place . The draThe drainage tubes were removed; the patient was discharged with per os administration of Amoxicillin/clavulanic acid for one week. The patient was scheduled for exploratory laparotomy two weeks later. At laparotomy there was a bowel-like mass, measuring 7 × 4 cm in size, that did not connect with the gastrointestinal tract and its mesentery . The cysThe patient was discharged from the hospital 3 days later and remained asymptomatic throughout a 1-year follow-up period.Alimentary duplication cysts were first described by Wendel in 1911. They are uncommon congenital lesions with a reported incidence of 1 in 4500 . By defiIn our case, the histopathologic examination revealed colonic mucosal lining. The cystic-like lesion's wall was similar to large bowel wall, infiltrated by chronic nonspecific inflammation. Enteric duplication cysts usually share a common wall with the normal intestine and have a common blood supply. “Isolated duplication” or “completely isolated duplication” of the alimentary are an extremely rare variety of gastrointestinal duplications. They are congenital cystic lesions having gastrointestinal epithelial and wall characteristics without an anatomic association with the alimentary tract , 9–13.In our case, the isolated duplication cyst had no anatomic association with the alimentary tract. There was no luminal communication with the adjacent ascending colon and the cystic mass had a separate vascular pedicle which debouched from retroperitoneal space.  More than 80% of enteric duplications present before the age of two years, usually with intestinal obstruction or a palpable mass , 4. MostIn our case, the first presentation was an unexplained intraperitoneal abscess. This drove us to affront it in the same way we usually treat intra-abdominal abscesses. Infection resolved with transcutaneous drainage in combination with intravenous and later per os antibiotics. During exploratory laparotomy, there were no signs of infection and the entire cyst was excised easily. In almost half of the cases, duplication cysts are associated with other malformations, mainly located in the vertebrae and genitourinary track. Horseshoe kidney was present in our case. Imaging studies like CT, MRI, ultrasound, colonoscopy, barium meal, barium enema, and recently endoscopic ultrasound  have beeInfected completely isolated enteric duplication should be considered in the differential diagnosis of unexplained intraperitoneal abscess. Percutaneous drainage of these “abscesses” is safe and effective during acute phase. Excision of the cyst is much easier and safer after the retreat of infection.


A 42-year-old male presented to the urology department, complaining of frequency and dysuria. A large number of calculi were revealed on IVU and USS. On endoscopic investigation, there were 3 stones (1.5 × 1 cm) found in the bladder and 5 more (1.5 × 0.8 cm) in the diverticulum of the posterior urethra. All of the stones were successfully broken down via a transurethral approach. This paper contains a detailed description of the case. A 42-year-old male presented to the urological department, complaining of frequent, painful, and difficult urination, which initially started a few years before. An occasional passage of small calculi was also noted to have taken place with urination. Two triangular shaped stones (1 × 0.8 cm in size) were reported to have passed during a period of an acute urinary retention a month before. A repeated acute urinary retention initiated the patient to approach a urologist. A total of 8 stones were revealed on IVU and the ultrasound study of the urinary tract. Stones, which were found on plain urography, were identical to the ones passed a month before, in terms of their colour and shape. The patient was offered a cystoscopy with an attempt of a transurethral stone extraction.A 12° optic 25 Fr cystoscope was passed in under spinal anaesthesia. The bladder was normal with no pathology identified. Urethra cystoscopy only revealed 3 triangular shaped, grey colored stones, whereas the IVU during the case visualised 8 well-defined shadows indicative of calculi. After removing the urethra cystoscope, a 26 Fr scope was inserted with a special ultrasonic lithotripsy probe for bladder stones. With the use of an ultrasound contact lithoclast, all 3 bladder stones were broken down and washed out. Further examination of the bladder neck revealed extra foramen on the posterior urethra at 7-8 o' clock position. An insertion of a nephroscope to this opening revealed a cavity with a mucosal looking inner layer, which contained 5 grey coloured, triangular shaped stones. With the use of a grasping forceps, the stones were relocated to the bladder, where they were successfully broken down and removed. The diverticulum was inspected following the clear out. It was found to be multichambered and extending directly under the bladder triangle. The prostate and the posterior urethra were found to be normal. The operation lasted a total of 90 minutes. After a successful trial without a catheter, the patient was discharged home the following day. Below are some of the illustrations recorded intra-operatively Figures Congenital diverticulum of the urethra is a rarely seen anomaly , 2. It pCongenital urethral diverticula are mainly located at the level of the anterior urethra, often associated to anterior valves and can be found on the ventral side of the urethra . The sizCongenital UD formation may be explained by an abnormal development in the area of ectodermal closing the urethral groove . Since t In our paper, we described a case of a large UD of the posterior wall in a male. This diverticulum was most likely congenital in origin, since no history of urinary infection, trauma, or catheterisation was reported. We found 12 other identical published cases concerning posterior urethral diverticula –9. Since


Dear Sir,Epidermoid cysts are slowly growing tumors that arise due to invagination of epidermis into dermis either spontaneously or following trauma. While common locations are the face, scalp, neck and trunk, external genitalia can also be affected with scrotal, labial or clitoral involvement. Clitoral location of this lesion may produce local sign of virilization in the form of clitoromegaly. This can cause significant parental worry and psychological disturbances in an older child. We report a girl with clitoromegaly due to epidermoid cyst.A 5-year-old girl presented with a painless swelling at external genitalia noticed since early infancy. Swelling gradually increased in size. There was nothing significant in antenatal and postnatal history. Genital examination revealed a firm cystic swelling arising from the clitoris. It was not tender, mobile from side to side and firmly attached to the base of the clitoris. Mass was covered by normal skin antero-laterally and with mucosa on the dorsum. Urethral and vaginal openings were normal . No signs of virilization were noted. Ultrasonography of the abdomen revealed normal ovaries and uterus. At operation, the cyst was excised through an inverted V shaped incision preserving the dorsal neurovascular bundles . Clitoral reconstruction was done. Wound healed satisfactorily. Gross appearance and histopathology of the specimen were confirmatory of epidermoid cyst. At 2 years follow up her external genitalia appeared normal with preserved clitoris .Causes of clitoromegaly can be hormonal, non-hormonal, pseudo-clitoromegaly, and idiopathic.[1] Endocrinopathies include: congenital adrenal hyperplasia(CAH) or adrenogenital syndrome, bilateral hilus cell tumor of the ovary, steroid producing gonadal tumors, adrenal androgen secreting carcinoma, Leydig cell tumor of the ovaries and metastatic carcino-sarcoma of the urinary bladder.[1-4] Common non-hormonal causes include neurofibromatosis (NF), epidermoid cyst, various syndromes and nevus lipomatous cutaneous superficialis etc.[4] A soft, mobile, non-tender mass in the clitoral region with absence of virilization is the typical physical finding, which is almost similar to ours. A detailed history and careful clinical examination can differentiate it from most of the other causes of clitoromegaly and spare the child from unnecessary investigations and can avoid delay in surgery.Objectives of the treatment are straight-forward excision of the cyst with preservation of sexual arousal function and sensation, and cosmetic appearance. This can be achieved by preservation of the neurovascular bundles during dissection.[1] An inverted V shaped incision, as described by Celik et al, preserves neurovascular bundles and clitoral skin for cosmetic reconstruction of the clitoris.[5] Same was applied in index case.Source of Support: NilConflict of Interest: None declared


Schwannoma is a neurogenic tumor originating from the nerve sheath Schwann cells. Intrathoracic location is rare, and the endobronchial location is exceptional. Schwannoma is a rare tumor; the majority of lesions are benign and usually asymptomatic. The authors present a case report of a 83-year-old woman, nonsmoker, observed in the emergency department for wheezing and cough lasting for 2 months. Chest tomography showed a right hilar pulmonary mass, ill defined, with thick and irregular walls, centered on the upper lobe bronchus, which was obliterated. Fiberoptic bronchoscopy showed a necrotic mass obstructing the right upper lobe bronchus whose biopsy allowed the diagnosis of benign schwannoma. Subsequently, the patient carried tumor ablation by laser bronchoscopy, with the resolution of the respiratory symptoms. This case stands out for its rarity but also because it is an excellent example of the importance of endoscopic techniques for therapeutic purposes. Schwannoma is a benign tumor in which surgical or endoscopic intervention generally prevents local recurrence and associated clinical manifestations. Schwannoma is a neurogenic tumor originating from nerve sheath Schwann cells. Intrathoracic location is rare, involving essentially the mediastinum, being its endobronchial location exceptional. Schwannoma is a rare tumor. The majority of lesions are benign and usually asymptomatic.A female patient, 83 years old, nonsmoker, was observed in the emergency department for wheezing and nonproductive cough for about 2 months. Her medical history revealed hypertension for the last 10 years; family history was unremarkable.Pulmonary auscultation showed decreased breath sounds in the upper third of the right hemithorax, without the reduction of vocal vibrations. Physical examination did not show any other relevant changes.Chest X-ray revealed a heterogeneous hypotransparency in the right hemithorax, upper third; blood count and blood biochemistry unchanged .To clarify radiological findings, a chest tomography (CT) was performed that showed a suprahilar right lung mass, ill defined, thick walled, and irregular, centered in upper lobe bronchus, which is obliterated, probably due to tumor necrosis . FiberopSubsequently, the patient was considered for laser therapy for tumor ablation. Rigid bronchoscopy was performed and a flexible fiberoptic bronchoscope was inserted through the rigid broncoscope for laser tumor ablation. The tumor was partially removed with the patency of the right upper lobe. The broncoscopic procedure had no immediate complications and the patient was discharged 24 h later without any respiratory symptoms.Unfortunately, no bronchoscopy or CT was done as a followup or to exclude recurrence because the patient had a fatal cerebrovascular stroke one month after the procedure.Schwannoma, also called neurinome or neurilemmoma, is a Schwann cells tumor, usually of benign histology, in the form of a well-circumscribed encapsulated mass arising from cranial or peripheral nerves , 2. Bronchial location is extremely rare. Schwannoma represents 4% of tracheobronchial tumors and 0.2% of bronchopulmonary tumors [Straus and Guckien first described three cases of tracheobronchial Schwannomas in 1951 , in a JaThere are two major types of neurogenic tumors in the bronchial tree: Schwannomas and Neurofibrome. Schwannomas are well-encapsulated tumors formed by the Schwann cells sheath, distinguished in two varieties: the Antoni type A, with dense tissue, rich in cells and Antoni type B, more lax and poor in cells. In Neurofibromes, by contrast, lesions are diffuse, ill defined, formed from Schwann cells tumor proliferation and fibroblasts from nervous connective tissue. Schwannomas and Neurofibromes with bronchopulmonary location are generally benign, although malignant cases have been described , 5. In Kasahara et al. review, Schwannomas were divided into two main types according to their location—central and peripheral. When the lesion is located proximal to the trachea or bronchus and it is visible in bronchoscopy, it is classified as central and may cause symptoms such as coughing and wheezing due to airway stenosis .Endobronchial neurogenic tumors occur preferably in young adults between 20 and 30 years old, but two cases were described above the age of 80 years old . Clinical signs are not specific, since this is usually a benign and slow evolution tumor, remaining asymptomatic for long periods, manifesting problems such as breathlessness, wheezing, or cough secondary to bronchial obstruction, or possibly by hemoptysis.Radiological changes depend on the tumor size, its location in the tracheobronchial tree, and the degree of obstruction that it determines. High-resolution CT scan allows an accurate detection of tumor topography, its density, changes in the bronchial structure, and ventilation, essential for future therapeutic attitude and followup . Fiberoptic bronchoscopy is essential to determine the level of obstruction, morphological aspect, and implantation type and for obtaining lesion biopsies in view of the histological diagnosis . SchwannThe ideal treatment is to excise the tumor and restore the bronchial patency . They caIn the presented case report, it was decided to perform a less invasive treatment with laser tumor ablation, given the patient advanced age and the risks of a major surgical intervention as a lobectomy were not negligible.Prognosis, in general, is good after the lesion complete excision. Relapses are exceptional. Histopathology is the cornerstone of Schwannoma diagnosis and bronchoscopy is the procedure of the choice for both diagnosis and treatment. This case stands out for its rarity, but also because it is an excellent example of the endoscopic techniques important for therapeutic purposes.Endobronchial Schwannoma should be present as a differential diagnosis in a patient with dyspnea, wheezing, and lung mass. It is a benign tumor and a surgical or endoscopic treatment usually prevent local recurrence and associated clinical manifestations.