Objective. To report a case of unusually widespread sporadic venous malformations of the head and neck associated with normal D-dimer levels and, due to the protean clinical manifestations and increased risk of coagulopathy of these lesions, to review their diagnosis and clinical management. Case Report. A 25-year-old man presented with a one-year history of intermittent right-sided neck swelling and tongue swelling. Physical exam revealed additional lesions present throughout the head and neck. There was no family history suggestive of heritable vascular malformations. Radiographic imaging demonstrated 15 lesions located in various tissue layers consistent with venous malformations. A coagulation screen showed a normal prothrombin time, activated partial thromboplastin time, international normalized ratio, D-dimer level, and fibrinogen level. It was determined that the patient was not at increased risk for intraoperative coagulopathy and preoperative heparin administration would not be necessary. The patient's buccal and tongue lesions were subsequently excised with no complications. The patient also underwent sclerotherapy evaluation for his neck mass. Conclusion. This case describes a unique presentation of sporadic multifocal venous malformations. It also emphasizes the importance of prompt diagnosis and workup when multiple venous malformations are present to prevent morbidity during surgical excision secondary to intravascular coagulopathy. Vascular malformations are a heterogeneous group of vascular aberrations encompassing a spectrum of subtypes differentiated by vessel type, flow rate, and size . Venous The lesions of MVM tend to be small and typically evade clinical diagnosis until adulthood. However, MVM have been associated with an increased risk of spontaneous thrombosis and thrombolysis, a condition termed localized intravascular coagulopathy (LIC). Severe LIC can potentially progress to disseminated intravascular coagulopathy (DIC) during surgical excision and thus mandates preoperative evaluation .An otherwise healthy 25-year-old male presented with a one-year history of intermittent right-sided neck swelling. He also reported nonspecific right buccal and left ventral tongue masses that had been present for over 8 months. These lesions caused occasional discomfort as well as cosmetic concern. The patient denied any history of similar findings in the past. He denied fevers and pain, ulcers, or bleeding from the sites. Swallowing, speech, and respiratory functions were unaffected. He denied any changes in bowel movements, hematochezia, or melena. There was no family history suggestive of a heritable form of venous malformations.On physical exam, a 3 cm × 3 cm area mass was noted on the right side of the neck at level 2. The area was soft and nontender and had no associated skin changes. A thorough dermatological exam yielded no additional cutaneous lesions. A 2 cm right buccal lesion and a 3 cm ventral tongue lesion were observed on inspection of the oral cavity . Both weT2-weighted magnetic resonance imaging (MRI) of the neck demonstrated the presence of 15 well-defined, variably sized, hyperintense lesions involving multiple tissues including the skin, mucosa, muscle, and viscera throughout the head and neck which were consistent with venous malformations. Lesions were found in the thyroid gland, left floor of the mouth, right suprahyoid posterior triangle, right posterior submandibular triangle, right supraclavicular fossa, and right lateral chest wall and superficial to the right superior trapezius Figures . ImportaD-dimer level (0.53 mcg/mL). The right buccal lesion was subsequently biopsied, confirming a CD31-immunoreactive, M2A-negative, and GLUT1-negative vascular lesion.The patient had prior blood work confirming HIV-negative status and a negative tuberculin skin test. A basic metabolic panel and complete blood count were unremarkable. Importantly, hematological investigations demonstrated a normal prothrombin time, activated partial thromboplastin time, international normalized ratio, fibrinogen level (219 mg/dL), and Management involved a multidisciplinary team consisting of a head and neck surgeon, a vascular malformation specialist, and a hematologist. Since the patient was not at an increased risk for intraoperative coagulopathy and given the superficial location, relatively small size, and normal venous drainage of the buccal and tongue lesions, complete surgical excision of these lesions was recommended. Heparin was not given preoperatively. The excisions were performed meticulously with no residual lesion, and an intraoperative frozen section confirmed the diagnosis of venous malformation. The patient was referred separately for sclerotherapy evaluation of the neck mass. The decision was made to observe and follow the remaining lesions for any clinical or symptomatic changes. In addition, the patient received counseling on molecular genetic testing, but he was subsequently lost to follow-up.Vascular malformations are slow-flow collections of ectatic vessels that are present at birth, grow throughout life, and do not involute spontaneously. Most lesions are occult in nature, as seen with our patient, but may manifest in adulthood as progressive swelling secondary to infection, trauma, or the hormonal changes of puberty or pregnancy . Dependi TEK) on chromosome 9p21 in VMCM and loss-of-function mutations in glomulin on chromosome 1p21-22 in GVM [ TEK. A thorough record of family history and possible genetic testing are thus key parts of the clinical evaluation. In this case report, the patient presented with disseminated multifocal lesions, no apparent family history, and normal D-dimer and fibrinogen levels. This constellation of findings has not yet been reported in the literature. Unfortunately, molecular genetic studies were not completed on the tissue, and it remains unknown whether a pathogenic variant in TEK is the etiology for this patient's MVM.Venous malformations are most commonly sporadic and unifocal, but MVM may occur and are often associated with a number of autosomal dominant genetic vascular anomalies, such as multiple cutaneous and mucosal venous malformations (VMCM) and glomuvenous malformations (GVM) . Disorde2 in GVM . Limaye 2 in GVM  concludeD-dimer levels, low fibrinogen levels, and extensive lesions of larger size and deeper tissue involvement [D-dimer fragments, a proposed biomarker for both venous malformations and the risk of coagulopathy [D-dimer levels. Patients with important or severe LIC, defined as D-dimer levels twice the upper limit of normal, require Low Molecular Weight Heparin started 10 days before surgery to prevent catastrophic intraoperative hemorrhage [Accounts of severe coagulopathies with MVM have been described and are frequently associated with high olvement , 5. Sponulopathy . This comorrhage , 5.Venous malformations are diagnosed clinically with a full head and neck examination and laryngoscopy and are subsequently confirmed and evaluated for origin and regional extension with imaging . DopplerTreatment is dependent on the size and location of the malformations and the presenting symptoms. Small, painless lesions may not necessitate intervention, but larger symptomatic malformations require medical or surgical management. Minor and superficial well-circumscribed malformations of the head and neck can be treated with surgical excision, which involves careful removal of the skin and mucosa to prevent reoccurrence, or Nd:YAG laser treatments , 11. SurD-dimer level with the degree of involvement that is seen in this case [Few reports in the English literature have described sporadic MVM, and none have described a normal his case . Althoug(1)D-dimer levels.Venous malformations are slow-flow vascular anomalies with protean clinical manifestations that can present focally or diffusely. We report a rare case of sporadic MVM with normal (2)D-dimer level is elevated.Severe coagulopathies such as LIC and DIC are associated with MVM, especially when the (3)The increased risk of severe coagulopathy necessitates a thorough preoperative assessment for subclinical coagulopathy and preventive treatment with heparin as necessary before intervention is determined.


At the time of diagnosis, an extracranial disease is found in over half of patients. The most common histology is the serous type. The median time from primary diagnosis to development of cerebral lesions is directly correlated to initial tumor grade and stage. Several therapeutic approaches can be proposed, including best supportive care +/- corticosteroids, surgery, radiotherapy and chemotherapy. A multimodal therapy approach may achieve an improved outcome and should therefore be utilized whenever applicable.Brain metastasis from epithelial ovarian cancer (EOC) is very rare with a reported incidence of less than 2%. It is usually associated with a poor prognosis that is related to several factors, the most important including: single We present the case of a patient with a solitary brain metastasis which appeared 11 years after a locally advanced and aggressive EOC (FIGO stage III C) and which totally regressed after surgery and adjuvant chemotherapy. Clinically, she showed progressive headaches, decreased visual acuity, balance and memory disorders associated with a confusional state. Brain CT scan and MRI documented a solitary, necrotic lesion in the left central parietal region with an important cerebral surrounding edema and initial cranial herniation. No other extracranial metastases were observed at the PET scan. Laboratory tests were in the normal range and CA 125 was moderatly increased at 81 UI/ml. The patient underwent surgical removal of tumor lesion, post-surgical whole-brain radiotherapy (WBRT) and systemic chemotherapy with carboplatin alone for six cycles. At a follow-up of 13 months, she is alive, in good clinical condition and tumor progression free.The peculiarity of this case relies on the isolated brain relapse of a BRCA-1/BRCA-2 non-mutated EOC, which is uncommon and rare, and to the very long time, of 11 years, from diagnosis of primary cancer and development of brain metastasis. A multimodal, aggressive approach of this isolated brain metastasis led to a complete and prolonged tumor control. Approximately 20–40% of all cancer patients develop brain metastases with breast cancer, lung cancer and melanoma representing the most common primary tumors. The repWe report an interesting case of a 63-year-old woman presenting an isolated EOC brain metastasis, 11 years after the primary tumor treatment.In Jun 2001, a 51-year-old woman was submitted to radical surgery followed by 6 cycles of systemic chemotherapy with a carboplatin/taxol regimen for a FIGO stage IIIC mixed, undifferentiated and clear-cells ovarian cancer. The follow-up was uneventful until July 2012 when an increase of the tumor marker CA 125 was observed at 46 UI/ml. A chest-abdomen and pelvic CT scan was also performed and it was negative. In December 2012, the patient was hospitalized because of progressive headaches, decreased visual acuity, balance and memory disorders associated with a confusional state. Brain CT scan and MRI documented a solitary, necrotic lesion in the left central parietal region with an important cerebral surrounding edema and initial cranial herniation  compatible with metastasis from ovarian primary .Brain metastases from EOC are very uncommon with a reported incidence in the literature of 1–2.5%. This inRadiologically, brain involvement is often multiple and presents a mixed, solid-cystic form. The froAbout 80% of the patients present a FIGO stage III or IV at the first diagnosis of EOC. The mosThe reported median time from primary diagnosis to development of cerebral lesions is variable and directly correlated to initial tumor grade and stage, 11.vs "multiple" localisations, the interval time from primary diagnosis and metastatic manifestation, tumor stage, grade, histotype, age at diagnosis of brain relapse, site of lesion, and treatment strategy[vs single lesions. Other factors, such as histology, age at primary diagnosis, ascites, residual tumor at primary surgery, extracranial disease at time of brain relapse, presentation with or without headache did not directly impact on OS. A trend for significatly longer survival for the multimodal therapy was also observed[Only two independent prognostic factors have been shown to have a relevant clinical impact: i) the presence of extracranial disease at the time of brain relapse and ii) the performance status. Conflicstrategy, 12. Howobserved.Germlime mutations of BRCA-1 and -2 genes have been reported in 10% of EOC and they seem to correlate with a more aggressive behaviour and a metastatic disease. RecentlSeveral therapeutic approaches can be proposed, including best supportive care +/- corticosteroids, surgery, radiotherapy and chemotherapy. When applicable, conventional neurosurgery promises the best results. In case of contraindications to surgery, inaccessibility of lesions and the presence of multiple metastases, the most commonly used individual therapy strategy is WBRT that improves neurological symptoms and prolongs median survival up to 3–6 months, 6.The role of systemic chemotherapy is controversial with a reported median OS up to 16 months even when combined with surgery or radiation, 7. ThesSeveral studies have documented an increased therapeutic potential by a multimodal, more aggressive approach.Cohen et al. reported a median OS of 5.6 months for surgery or WBRT, when these are employed individually, and of 23.1 months after a combination of both strategies. RecentlA multimodal therapy approach may achieve an improved outcome for the patients and should therefore be used whenever applicable. The evidence available to date is pointing towards a combination of surgery and radiotherapy as the treatment modality with the best benefit to drawback ratio. An addiIn our case, the patient presented a solitary brain metastasis 11 years after a locally advanced and aggressive EOC which totally regressed after surgery and post-surgical chemotherapy. Brain involvement was associated with a moderatly increase of tumor marker CA125. No other extracranial metastases were observed. The patient underwent a multimodal and aggressive treatment, including surgical resection of the tumor lesion, post-surgical WBRT and systemic chemotherapy with carboplatin alone for six cycles that led to a complete and prolonged tumor control.The peculiarity of this case relies on the isolated brain relapse of a BRCA-1 and BRCA-2 non-mutated EOC, which is uncommon and rare, and to the very long time, of 11 years, from diagnosis of primary cancer and development of brain metastasis. Finally, a multimodal and aggressive approach achiewed a prolonged tumor-free survival.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 of this journal.


Dear Sir,Meckel’s diverticulum was first described in 1598 by Hildanus. Meckel’s diverticulum is said to be present in 2 % of population. It is twice as common in males as opposed to females. Most of the symptomatic cases present within the first 2 years of life. It may get inflame or perforate . Its presentation as perforation is rarely seen in neonatal period.A 7-day-old neonate weighing 2.5kg was referred to our department with abdominal distention for four days and absolute constipation for 2 days. The baby was born by C-Section at full term and was given rose water and few sips of cow’s milk after birth. He passed meconium normally. The baby started bilious vomiting on 2nd day of life followed by abdominal distention on the next day. On 7th day the abdomen became tense. On clinical examination the patient was tachypneic and the abdomen was tense and distended. Bowel sounds were absent. Rectum was empty on rectal examination. The laboratory investigations showed a deranged clotting profile. An erect abdominal x-ray was advised for the suspicion of a perforation, which showed free gas under the diaphragm.A peritoneal drain was passed while the child was optimized for surgery. After normalizing the coagulation profile, surgery was performed. Intra-operatively the small bowel was adherent with inflammatory flakes all over it. A perforated Meckel’s diverticulum was found after mobilization of the gut . The Meckel’s diverticulum with a small ileal segment was resected and an end to end anastomosis was performed. A pelvic drain was also placed. The immediate recovery was uneventful; however, the baby developed sepsis on 6th postoperative day and succumbed.About 3-4% of Meckel’s diverticulae become symptomatic and perforation occurs in 10% of symptomatic cases. Pneumoperitoneum in a neonate is a serious entity and most of times indicate bowel perforation. In neonates the etiology of pneumoperitoneum is necrotizing enterocolitis, mechanical obstruction like atresia and stenosis, meconium ileus, hirschsprung’s disease, anorectal malformations etc. or it can be a spontaneous perforation. Meckel’s diverticulum perforation presenting with pneumoperitoneum is seldom reported in literature [2].The etiology of perforation of Meckel’s diverticulum as described by various authors are acute inflammation with ectopic pancreatic or gastric mucosa, acute inflammation without any ectopic gastric or pancreatic mucosa, congenital focal muscular defect of diverticulum, narrow lumen with poor self emptying, and spontaneous perforation .In our case the baby was full term and otherwise healthy. There was no history of perinatal distress or asphyxia. The histopathology did not reveal ectopic gastric or pancreatic mucosa; therefore the likely cause of perforation in our case could be spontaneous.In conclusion, despite the rarity of the perforated Meckel’s diverticulum in neonates, it should be considered as one of the differential diagnosis of acute abdomen and pneumoperitoneum.Source of Support: NilConflict of Interest: None declared


Acinar cell cystadenoma (ACA) of the pancreas has been newly recognized as an entity by the World Health Organization (WHO) definition (2010), and its pathogenesis has not been known adequately because of the rarity. Here, we report a case of a 22-year-old female who had been followed up for a cystic lesion at the tail of the pancreas pointed out by a screening computed tomography (CT) scan 7 years ago. The tumor grew in size from 3.3 to 5.1 cm in diameter for 6 years (0.3 cm per year). Particularly, it rapidly grew up to 6.3 cm in the latest 3 months in concurrence with the emergence of epigastralgia. A contrasted CT scan revealed the irregularly formed, multilocular cystic tumor having thin septum and calcification. The intratumoral magnetic resonance imaging intensity in the T1 and T2 weighted images were low and high, respectively. No communications between the tumor and the main pancreatic duct (MPD) were found, but the tumor displaced the MPD. She underwent surgical resection because the tumor was growing, turned symptomatic, and it seemed difficult to be diagnosed correctly until totally biopsied. Spleen-preserved distal pancreatectomy was performed. It was pathologically diagnosed as ACA; the cyst was lined by cells with normal acinar differentiation; cuboidal cells with round, basally oriented nuclei and eosinophilic granules in its apical cytoplasm. The abdominal pain has disappeared, and no recurrences have been found during a 5-year follow-up. Clinicians are recommended to consider an ACA as one of differential diagnoses of cystic tumors of the pancreas to provide appropriate diagnostics and therapeutics. Acinar cell neoplasms of the pancreas is a rare disease representing only 2 % of pancreatic neoplasms . Acinar A 22-year-old female had been followed up annually at a former hospital for a cystic mass at the tail of the pancreas, which had been pointed out by a screening computed tomography (CT) scan to diagnose an acute abdomen, such as peritonitis and ovarian torsion, when she was 15 years old Fig. . EndoscoMucinous cystic neoplasm (MCN), serous cystic neoplasm (SCN), and branch duct intraductal papillary mucinous neoplasms (BD-IPMN) were considered as differential diagnoses. According to IPMN/MCN guidelines , surgicaIntraoperatively, we found a very soft and multilocular cystic tumor having a thin capsule without adhesion or invasion to the adjacent tissues. Because the tumor was unlikely to be malignant, we performed a spleen-preserved distal pancreatectomy without a systemic lymph node dissection. Splenic artery and vein are also preserved. The cut line was easily determined because the tumor was well-demarcated macroscopically. Intraoperative ultrasonography also showed no evidence of mural nodules. We also ensured that the resection margins were cancer-free by examining intraoperative frozen sections. The lesion is comprised of very soft and multilocular cysts containing serous fluid and focal calcification Fig. . The posIn pathological examinations, a cystic lesion lined by cells with acinar differentiation was pointed out. The nuclei are uniform and basally oriented without atypical changes Fig. . In immuHere, we reported a surgical case of an ACA of the pancreas, which showed interesting radiologic features and clinical courses. We have clarified the description of the MPD image, based on the results of ERP.Acinar cell neoplasms are recognized as a rare entity. Particularly, ACAs, lined by cells with acinar differentiation without atypical changes, are reported to be extremely rare . The acihttp://www.ncbi.nlm.nih.gov/pubmed) [ACA incidentally detected during autopsy was first reported in April 2002 . After t/pubmed) , 3–13. AIn the literature review, females are predominant . Approximately two thirds of the patients had complains of an abdominal pain or discomfort. Postoperative follow-up period was widely ranged from 5 months to 11 years. There has not been any case reported on recurrence or evident malignant transformation so far. Whether ACAs is a congenital disease is dismissive so far because the age of the patients widely ranged 9–71 years old (mean 42.9 years). The most typical radiological appearances of ACAs are reported to be homogeneous hypovascular cystic tumors with thin septum. They show hypodensity in CT images, low intensity on the T1-weighted MRI, and high intensity on the T2-weighted MRI . UsuallyHowever, it is hard to distinguish from other cystic tumors of the pancreas exclusively by imaging only because ACAs have less definitive morphologic features. The size of ACAs was reported to have a wide range from small incidentaloma to large tumor-suspected malignancy. Moreover, some ACAs diffusely involved entire pancreatic grand or increased in diameter during long-term follow-up. The most frequent site of ACAs was reported to be the head of the pancreas . Most of ACAs were solitary but some (approximately 10 %) of them have diffuse disease. The prevalence of unilocular or multilocular forms was equivalent. Less than 10 % of ACAs showed a communication to the MPD like BD-IPMNs. Eight cases of them are reported to have calcifications inside the tumor, and it is known to be a similar finding as SCNs. Some of them have thick capsules, which is frequently seen in MCNs. In the literature, pre-operative diagnoses are IPMN (eight cases), MCN (three cases), SCN (one case), and neuroendocrine tumor (one case), etc.Although even EUS-guided fine-needle aspiration was performed in 21 cases, none of them were diagnosed as ACAs because of its hypocellularity . AccordiERP of the presented case clearly described that an image of MPD which is not connected to any cyst or without stenosis differs from images common to IPMN and other malignant tumors. Furthermore, small branches of the pancreatic duct were detected, suggesting that the tumor was soft and plastic. Surgical findings were also in agreement, providing further evidence for acinar metaplasia. Relative to MRP, which most previous reports presented, ERP can provide more precise information on the pancreatic duct without interference by cystic lesions. These finding may be useful in distinguishing ACAs from other cystic neoplasms, although it is not definitive.Histologically, the surface of the cystic walls consists of one or several cell layers with normal acinar cells; cuboidal cells with round, basally oriented nuclei and eosinophilic, periodic acid stain (PAS)-positive granules in its apical cytoplasm. Mitoses are rarely observed , 4, 11. The pathogenesis of ACAs remains unclear. Now, it is assumed that acinar metaplasia could be the main pathogenesis of ACAs based on results of the immunohistochemistry . HoweverAt present, although ACAs are finally diagnosed by pathological examination of surgical specimen, we would like to propose two approaches when you encounter cystic lesions. First, the diagnostic clues of ACAs can be proposed from our experience and the literatures as follows: younger females, round-shaped cystic tumor without evidence of the MPD stricture, no communications to the MPD (unlike IPMN), thin capsules (unlike MCN), and non-honeycomb type (unlike SCN). Second, modification of the general approach may be preferable when the ACAs are included in the differential diagnosis of the cystic mass. Occasionally, total pancreatectomy or pancreatoduodenectomy are required for resection when the lesions, suspected of being malignant, are multiple, diffuse, or located in the pancreatic head. In such situations, surgical biopsy, which is not included in the guidelines for the management of IPMN and MCN , can be Here, we reported a rare surgical case of ACA following a long-term surveillance. It showed interesting radiologic features and clinical courses. Clinicians are recommended to consider an ACA as one of differential diagnoses of cystic tumors of the pancreas to provide an appropriate treatment.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.


Dear Editor,Here, we present the case of a 34-year-old woman who suffered postoperative pain andfever after subtotal abdominal hysterectomy. Conventional radiography of the pelvisshowed unilateral sacral curvature .Compute-3. ASM is a rare form of spinal dysraphism, in which themeningeal sac herniates into the presacral space,5. It accounts forapproximately 5% of all retrorectal masses and is more prevalent in women.Various conditions related to anomalies in central nervous system development have beenreported in Brazil,8. Due to its occult nature, it is generally diagnosed inthe second or third decades of life. It can be asymptomatic or present with nonspecificsymptoms, such as constipation, urological symptoms, and, in rare cases, neurologicalsymptoms. The diagnosticinvestigation can include conventional radiography, ultrasound, CT, and MRI.ASM can occur in isolation or in association with other congenital abnormalities, such asurogenital malformations, anorectal malformations, lipoma, teratoma, epidermoid tumor,and dermoid cyst. Abdominal ultrasoundcan show a retrovesical cystic lesion, unspecific to the method. CT is an important tool, because itprovides detailed information on associated bone alterations and can reveal herniationof the meningeal sac. MRI is the test of choice for evaluating ASM, because it createshigh contrast between soft tissues, which makes it able to detect any communicationbetween the ASM and the subarachnoid space, and provides detailed information aboutother related abnormalities that might be present. However, when a communication with the subarachnoid space isnarrow, MRI can fail to show it. In such cases, myelography with intrathecal injectionof contrast can be necessary.With conventional radiography, it is sometimes possible to observe a "scimitar sacrum",characterized by an unilateral sacral curvature, which is considered pathognomonic forASM,13: tumors of the gastrointestinal or genitourinarytract; epidermoid or dermoid cysts; aneurysmal bone cyst; hamartoma; hydatid cyst;lipoma; lymphangioma; perineural cyst; rectal duplication cyst; gynecologic tumors;teratoma; or teratocarcinoma. The most important means of establishing the definitivediagnosis is detecting communication between the cystic lesion and the subarachnoidspace.The differential diagnosis of ASM includes cystic lesions located in the presacralregionIn the case in question, making the diagnosis of ASM was particularly important becausethe patient underwent laparotomy to drain the hemorrhagic collections in the pelvis.During that procedure, an unwarranted, inadvertent intervention in the meningocele couldhave had disastrous consequences.


Phosphoglyceride crystal deposition disease (PGDD) is a rare disease entity that is characterized by phosphoglyceride crystal deposition that stimulates the formation of masses in soft tissue scars or bones. We report a case of PGDD in the pelvic soft tissues that recurred after initial surgical treatment. A 50-year-old woman was referred to our hospital for the evaluation of pelvic masses that were observed on an abdominal ultrasound. Magnetic resonance imaging (MRI) revealed masses in the pelvic region, with the largest being 10 cm in diameter. The masses were diagnosed as ovarian malignant tumors, and an exploratory laparotomy was performed. Operative findings revealed them to be foreign body granulomas, and the patient was diagnosed with PGDD. The patient had a history of cesarean delivery at the age of 24 years. PGDD is extremely rare, but it should be considered in the differential diagnosis of abdominal masses in patients with a history of abdominal surgery. Phosphoglyceride crystal deposition disease (PGDD) is characterized by phosphoglyceride crystal deposition that stimulates neoplasia in soft tissue scars or bones . As thisIn this report, we describe a case of PGDD in the pelvic soft tissue, which was treated surgically after being initially misdiagnosed as ovarian malignant tumors and recurred twice.A 50-year-old Japanese woman was referred to our hospital for the evaluation of pelvic masses. This abnormality was observed on an abdominal ultrasound which she underwent as part of a routine check-up. The patient had a history of a cesarean delivery at the age of 24 years without any postoperative complications and had no significant family history.On the first medical examination, the pelvic masses were detected by transabdominal ultrasound, and the largest mass was approximately 10 cm in diameter . All labMagnetic resonance imaging (MRI) also revealed lobulated masses in the pelvic region, with the largest being 10 cm in diameter. The masses contained a hemorrhagic component, as well as a central solid part that exhibited a low intensity on T2-weighted images Figures . Some smMasses that adhered to the parietal peritoneum and the bladder were detected at the vesicouterine pouch. A part of the omentum had also adhered to the masses, and some swollen omental lymph nodes were observed. Dissemination-like small masses, which had torn from the omentum and the peritoneum, were also detected at the peritoneum of the vesicouterine pouch. Other masses were detected at the Douglas cavity, but these were strongly attached to the rectum, making excision impossible. Both ovaries were normal sized, but a small dissemination was detected on the surface of the right ovary. A tumor of peritoneal origin was suspected, and tumor debulking, bilateral salpingooophorectomy, and omentectomy were performed.α1-antichymotrypsin, and MIB-1 (10%) but negative for p53 antibody. These masses were diagnosed as granulomas, without a mixture of epithelial cells or other cell components. The central crystal was determined to be phosphoglyceride by the gold hydroxamic acid method , a mass with a diameter of 3 cm was detected at the vesicouterine pouch and was considered to be the same granuloma. The mass was observed on ultrasound in an outpatient clinic, but irritative bladder symptoms had appeared with its growth, and an MRI revealed a mass 5 cm in diameter at the vesicouterine pouch. The patient's symptoms worsened during the observation period, and she was operated on the third time. Since the masses strongly adhered to the uterus, a total hysterectomy was performed. An ileal stricture was detected, and an ileectomy was also performed. All excised masses were diagnosed as PGDD. At 18 months since her last operation, the patient has had no symptoms of recurrence.PGDD is a rare disease defined as phosphoglyceride crystals deposited as tumors in the soft tissue or bone with no relation to the joint . Phosphoμm in diameter, appearing as oval pink or blue aggregates on hematoxylin and eosin staining, and are arranged in corona-like circles. On polarized light microscopy, the fibrillar crystals appear refractive. The crystals do not dissolve in the usual specimen creation process, characteristically dissolve in acetic acid with oxygen gas formation, easily dissolve in alkalis, and stain positive for phosphoglycerides by the gold hydroxamic acid method.Histologically, PGDD is a foreign body granuloma consisting of crystals. Many histiocytes and macrophages surround the crystal and form foreign body granulomas. The crystals are 50–150 There are other deposition diseases such as gout, pseudogout, or calcium pyrophosphate. Although most of the above crystals accumulate in and around joints, phosphoglyceride crystals have shown no association with the joints and exhibit characteristics quite different from those of the above. A large mass can sometimes form and be misdiagnosed as a malignant tumor. To our knowledge, only 8 cases of this deposition disease have been reported previously, and little is known of the etiology and pathogenesis of this disorder. No sex predilection, congenital abnormalities, or family history of metabolic disorders has been noted in connection with this disease entity. Deposition sites were characteristically intramuscular injection sites or postoperative sites including the buttock muscle , brachiaIn this case, an exploratory laparotomy was performed for a suspected malignant tumor of the ovary by MRI. This patient had a history of cesarean section at the age of 24 years, and local inflammation at the operation site was suspected to have led to a progressive amplification of macrophage infiltration and crystal deposition. The previous cases in former reports  were alsPGDD is an extremely rare condition, but it should be considered in the differential diagnosis of abdominal masses in patients with a history of abdominal surgery.


Xanthogranulomatous pyelonephritis (XGP) is a rare renal tumor that arises as a complication of chronic obstructive pyelonephritis of uncertain etiology. It is primarily an adult tumor seen occasionally in children associated with urinary tract obstruction due to congenital urological anomalies, nephrolithiasis, and recurrent urinary tract infections. Radiologically, it may show neoplastic features such as those seen in common pediatric renal malignancies like wilms’ tumor and renal cell carcinoma. This overlap in radiological manifestation frequently leads to misdiagnosis and delay in appropriate intervention. We report a case of a 3 years old boy who presented with history of recurrent urinary tract infections and a left renal mass initially thought to be Wilms’ tumor.We present a case of a 3 years old boy admitted to the Pediatric oncology unit at Muhimbli National Hospital in Dar es Salaam, Tanzania with one year history of recurrent fever and urinary tract infection signs and symptoms refractory to antibiotic therapy. He was eventually found to have a left kidney mass detected at the District hospital by abdominal ultrasound performed to evaluate a flank mass that was felt by his mother. He was then referred to our unit for a suspicion of Wilms’ tumor which finally turned out  to be a left kidney Xanthogranulomatous pyelonephritis.He underwent a successful left nephrectomy and was discharged from hospital in a stable clinical condition and remains asymptomatic at the time of submission of this case report.This case report underscores the need for clinicians attending a febrile child with a renal mass that can be confused with common pediatric renal malignancies such as Wilms’ tumor to broaden their differential diagnosis. The case also underlines the significance of individualized patient evaluation because this patient would have otherwise received preoperative chemotherapy under the International Society of Pediatric Oncology (SIOP) guidelines if the diagnosis of Wilms tumor was not ruled out. Xanthogranulomatous pyelonephritis is a rare renal tumor of uncertain etiology believed to occur as a complication of chronic obstructive pyelonephritis with bacterial superinfection. It is more of an adult disease with peak age at 5th to 6th decade of life, occasionally seen in children associated with urinary tract obstruction mostly from congenital urological malformations such as posterior urethral valve, nephrolithiasis, and recurrent urinary tract infections . RadioloA 3 years old boy presented with history of recurrent fever, episodes of painful urination, increased frequency and haematuria for one year. He had been treated with several courses of antibiotics for urinary tract infections with temporary relief of symptoms before recurrence. At initial presentations several urine analysis using dipstics were performed at the local dispensary and reported to show features of urinary tract infections but no further work up such as urine culture, voiding cyctourethrogram or abdominal ultrasound was performed. Three months before admission to our unit, his mother had felt a mass on his left flank and an abdominal ultrasound done at the nearby District Hospital suspected Wilms’ tumor and the patient was referred to our unit for further evaluation. The patient had otherwise attained his developmental mile stones as per age and had no any dysmorphic features.On examination; the child was febrile with body temperature of 38.8 °C with tenderness on the left lumber region and had a palpable mass on the same side. Laboratory investigations performed are summarised in the concise table below; Table A repeat abdominal ultrasound showed a left renal mass 7.4X7.1X5 cm with multiple cystic lesions. The renal pelvis was destroyed with some calcific changes but no extension to the neighboring structures were noted. The right kidney was normal in size and echogenicity.Abdominal CT Scan Figs.  and 2 shBased on the clinical presentation and abdominal CT scan, a clinical diagnosis of Xanthogranulomatous pyelonephritis was made and the patient underwent left radical nephrectomy. Intra-operatively an enlarged yellowish grey left kidney with multiple mesenteric and hilar lymph nodes was seen, radical left nephroureterectomy and hilar lymphnode resection was performed, the right kidney was normal on inspection. The resected tissues were sampled and sent for culture and sensitivity but there was no bacterial growth after 7 days. Histological studies reported macroscopically gross yellowish renal tissues microscopically showing a renal histology infiltrated with foamy lipid laden macrophages in a mixture of chronic inflammatory cells and fibrosis confirming a diagnosis of Xanthogralomatous pyelophritis Fig. .Fig. 3H&The patient faired well postoperatively and was kept on a 7 days course of intravenous Tazobactam/piperacillin and discharged home 10 days post nephrectomy. E.coli, Proteus mirabilis, and occasionally Pseudomonas species [Xanthogranulomatous pyelonephritis is a rare chronic obstructive pyelonephritis characterized by infiltration of the renal parenchyma with lipid laden Macrophages and an enlarged non-functional kidney . It is m species . Renal c species . The affProteus species, Escherichia coli and Pseudomonas species in a setting of impaired ability of the body to clear the infection. Congenital urinary tract malformations are highly linked with development of XGP in children [In most cases, Xanthogranulomatous pyelonephritis involve one kidney but cases of bilateral renal involvement have been published , 8. XGP children . Ultrasochildren .On abdominal CT scan, our patient showed foci of calcifications with no calculi but renal calculi (frequently of staghorn proportions) are reported in up to 80 % of cases with XGP.XGP can manifest with malignant features capable of local tissue invasion and destruction explaining the frequent confusion with renal neoplasm hence it is often referred to as a pseudo tumor .Our case presented with one year history of antibiotic refractory urinary tract symptoms and fever, which is a typical presentation of this condition . The obsIf XGP is unilateral, serum creatinine and urea are usually normal, except for cases of bilateral extensive disease destroying both kidneys in which case long-term renal replacement therapy is required. Urine analysis reveals leukocytosis, proteins and culture may be positive for bacteria which also helps to ascertain the antibiotic sensitivity pattern .Surgery remains the mainstay for a definitive diagnosis and cure of Xanthogranulomatous pyelonephritis (XGP) requiring extirpation (nephrectomy) as the standard surgical technique but for small tumor, partial nephrectomy can be attempted. In most cases extirpation is necessary because the disease results in an infected, nonfunctioning kidney. Nephron-sparing surgery is an option, especially in cases of bilateral disease with demonstrated significant residual functional renal tissues . LaparosProteus species and E coli are usually sensitive to several antibiotics, including first-generation cephalosporins which can be started empirically pending sensitivity results [Pseudomonas species has a narrow spectrum of sensitivity and usually require the use of aminoglycosides, third-generation cephalosporins, or fluoroquinolones. For non-septic patients and those evaluated on an outpatient basis, some authors recommend use of oral antibiotics until surgery, at which point intravenous antibiotics should be administered [Medical therapy with antibitics only has been effective for treatment of XGP in a handful of cases but may be appropriate as a temporary measure for patients requiring workup before nephrectomy and prophylactic antibiotics should be administered before and after surgical intervention. The choice of antibiotic has to be tailored toward the identity and sensitivity of the offending organism.  results . Pseudomnistered . There inistered , 25. OurThis case report highlights the importance of clinicians attending children presenting with fever and renal mass to broaden the differential diagnosis for Wims’ tumor the commonest childhood renal neoplasm to exclude benign tumors, which can be cured by surgical resection and avoid exposure to chemotherapy especially if treatment is to be given using the European (SIOP) guidelines.XGP, Xanthogranulomatous pyelonephritis; CT, computed tomography; WBC, white cell count; RBC, red blood cell; MCV, mean corpuscular volume; MCH, mean corpuscular hemoglobin


A 47-year-old woman with a history of nephrolithiasis complicated by chronic renal failure presented with recurrent left flank pain. Nine months ago, she had been subject to an open surgery for left kidney pyonephrosis. She described a short febrile post-operative period; however, there had been no fever for the last eight months. On physical examination, she was afebrile and had a palpable tender mass in the left flank to suggest malignancy. Unenhanced abdominal CT showed a well-encapsulated ovoid heterogeneous mass, located within the left lumbar region (A). The mass resection was done (B). The patient tolerated the procedure and the postoperative period was uncomplicated. Since pathological examination showed retained surgical sponges surrounded by fibrous capsule as foreign body reaction (C), gossypiboma was diagnosed. A gossypiboma refers to a cotton-based foreign body left inadvertently in the human body following a surgical procedure. Gossypiboma is an uncommon condition, diagnosed preoperatively in only one third of all cases. New-onset or a recurrent tumor is the most common differential diagnosis. Gossypiboma should be considered in any postoperative patient presenting with pain, infection, or a palpable mass, particularly in countries where strict surgical protocols may not be in place.


Synovial sarcoma (SS) is a rare tumor originating from mesenchymal tissue and accounting for approximately 5–10% of all soft tissue sarcomas. A rare case of primary pulmonary SS in an asymptomatic 18-year-old man admitted to our hospital for investigation of a 6 × 6.5 cm, oval-shaped, well-delineated pleural based peripheral mass in the left lower lobe in his thorax CT is presented. Left lower lobectomy was done. Immunohistochemically, tumor cells were positive for cytokeratin, epithelial membrane antigen (EMA), and vimentin so that the histopathological diagnosis was compatible with biphasic spindle cell type SS in the lung. Synovial sarcomas (SS) account for nearly 5–10% of all soft tissue sarcomas . ClinicaAn 18-year-old man was referred for investigation of a peripheral opacity in the left lung lower lobe, which was discovered incidentally on a chest radiograph. The patient is a student and has a 6-pack/year smoking history. He was in good general health and well nourished. Physical examination was normal. The results of blood tests and standard biochemical tests were normal.Posteroanterior chest X-ray  revealedThorax CT angiography was taken to reveal vascular relation of the tumor. Heterogeneous contrast enhanced 6,5 × 4,5 × 6 cm mass lesion located at posterobasal segment of the left lung lower lobe was seen . No vascLeft posterolateral thoracotomy was performed. At lower lobe of the lung a big tumor at posterobasal segment was observed. The tumor was under the visceral pleura. Subsequently left lower lobectomy was done with dissection of the mediastinal lymph nodes. Histopathological evaluation revealed well-circumscribed nodular 8 × 6.5 × 6 cm mass. The tumor was adjacent to the visceral pleura but did not invade it. Microscopically the tumor was having spindle cells arranged in a dense cellular network. Immunohistochemically, tumor cells were positive for cytokeratin, epithelial membrane antigen (EMA), and vimentin so that the histopathological diagnosis was compatible with biphasic spindle cell type SS in the lung . A molec18F-FDG PET/BT) evaluation and oncological and orthopedic consultations, SS was accepted to be primary pulmonary. He received 3 courses of chemotherapy (adriblastina and ifosfamide). One year later two nodules, one at residual left upper lobe and a second at right lower lobe, occurred. The nodules were resected sequentially via wedge resections of the lobes. At the third year of followup, second recurrence occurred at residual left upper lobe. Due to small volume of the residual left lung, completion left pneumonectomy with chest wall resection was done. After the completion pneumonectomy the patient received adjuvant chemotherapy for six courses with adriblastina and ifosfamide. One year later locoregional recurrence at the pneumonectomy area and also a nodular metastasis at the right lower lobe superior segment and vertebral metastasis at T6–T8 vertebrae were detected. Then, the patient received radiotherapy (10 × 300 cGy) for vertebral metastasis. The patient died after two months.After positron emission tomography/computed tomography with 18F-fluorodeoxyglucose (SS is a rare tumor originating from mesenchymal tissue and accounting for less than 0.5% of all soft tissue sarcomas , 2. Age The presented case has a well-delineated peripheral mass in the chest X-ray which was compatible with the earlier reported series done by Frazier et al. in which 78% of the cases have lesions with well-delineated borders . Also thTumor does not originate from the synovial membranes but just resembles synovial tissue tumor under the light microscopy , 2. HistTreatment of these tumors is wide surgical resection with removal of the tumor with free surgical margins with or without radiotherapy for local control. Adjuvant chemotherapy for soft tissue sarcoma is controversial , 10. CurIn conclusion primary pulmonary SS is a rare and aggressive tumor. It should be diagnosed with radiological properties, histological methods, and molecular techniques as early as possible after other alternative diagnoses were excluded and wide resections were needed for the treatment of these tumors. Also due to high risk of recurrences, a long-term followup will be needed.


Cervical thymic cysts (CTCs) are unusual lesions, representing only 1% of cystic cervical masses. Diagnosis of this condition in adults is even rarer. We report a 34-year-old female who presented with asymptomatic progressively growing left-sided neck swelling. Neck ultrasound (US) showed a large cystic lesion with septation, compressing the ipsilateral vessels. Magnetic resonance imaging (MRI) confirmed the US findings. Surgical excision was performed which subsequently showed findings consistent with CTC. CTC in adult is extremely rare, with few reported cases identified in the literature. Thymic gland anomalies in the neck are the consequences of an arrest in the descent of the gland, sequestration of the thymic tissue, or failure of involution. The diagnosis of this condition is rarely done prior to surgical excision. The clinical presentation, radiologic imaging, surgical findings, and histologic appearance are all essential components to make the correct diagnosis of this very rare differential diagnosis of cystic lateral neck swelling.  Cervical thymic cysts (CTCs) are unusual lesions usually presenting in the 1st decade of life and representing only 1% of cystic cervical masses .We report here a rare case of a patient with CTC in an adult that was diagnosed after being excised, describing radiological, intraoperative, and histopathological findings. Moreover, CTC is seldom considered in the differential diagnosis of the neck masses preoperatively, making it an interesting case for publication.Our case was a 34-year-old female not known to have any chronic medical illnesses. The patient was referred to our hospital from the primary care center for left-sided neck swelling of 1-year duration. The swelling was discovered incidentally and gradually increased in size over time with no history of pain, increased body temperature, discharges, loss of appetite, change of voice, or pressure symptoms. There was no significant family history. Physical examination revealed a left-sided neck swelling, 6 × 3 cm, nontender, oval in shape, firm in consistency, and not pulsatile or increased with Valsalva maneuver and was mostly located beneath the sternocleidomastoid muscle. On laboratory workup, she was not found to have any related abnormalities. Neck US showed a large cystic lesion with septation measuring 5.9 × 2.3 cm, compressing the ipsilateral vessels, with no vascularity  remThe diagnosis of cervical thymic tissue is rarely made preoperatively . The difThree major imaging modalities are used to aid diagnosis. Ultrasound has been reported as useful in distinguishing cystic versus solid structures, assessing proximity to the carotid sheath, and, in some instances, identifying thymic tissue specifically by echo patterns . CT giveSurgery is the treatment of choice and helps to establish the definitive diagnosis . TransveHistopathologically, thymic cysts are unilocular or multilocular containing brownish fluid. The cyst wall lining ranges from flattened squamous or cuboidal cells to multilayered stratified squamous epithelium and to even primitive respiratory epithelium. Lobulated lymphoid tissue in the cyst wall contains Hassall's corpuscles .CTC in adults is extremely rare, with few reported cases identified in the literature. The clinical presentation, radiologic imaging, surgical findings, and histologic appearance are all essential components to make the correct diagnosis of this very rare differential diagnosis of lateral cystic neck swelling.


Urinary tract endometriosis and endocervicosis are an uncommon pathologic finding, with a common embryological origin. We present 2 cases of female patients with bladder mass. The first one was a finding of a nodular formation in the bladder during study of a nonviable foetus and the second was an incidental finding of a neoformation in the fundus of the bladder during the realization of an ultrasound. In both cases, we performed a surgical management with transurethral resection. Histopathological examination revealed a bladder endometrioma in the first case and endocervicosis with associated endometriosis in the second. Endometriosis is a chronic condition, usually gynaecological, of unknown cause. It is characterised by the presence of functionally active endometrial tissue (glandular epithelium and stroma) outside the uterine cavity, which induces a chronic inflammatory reaction. It is estimated to affect 5–10% of women of reproductive age, although in patients who present with pelvic pain the figures vary from 40 to 60% and among patients with sterility or infertility issues, the frequency of endometriosis reaches 20–40% [The most common sites for external endometriosis are the ovaries, uterosacral ligaments, ovarian fossa, peritoneum of the Pouch of Douglas, and rectovaginal septum. It is less frequently found in the cervix, vagina, and vulva and is rare in the urinary (bladder and ureter), gastrointestinal, and respiratory tracts. Implants have been described in the skin and laparotomy scars, especially after Caesarean sections .There is also a type of intramyometrial endometriosis known as adenomyosis, which can likewise be caused by Caesarean sections in hysterectomy scars. It is associated with an increased risk of placenta accreta and uterine rupture, and ectopic pregnancies have also been described in this location .Bladder endometriosis is defined as the ectopic presence of endometrial tissue, glands, and/or stroma that invade the detrusor muscle and/or other planes of the bladder wall in an extrauterine site.Involvement of the urinary tract is rare, occurring in only 1-2% of women with symptomatic endometriosis and affecting the bladder in most cases.We present two cases, one of isolated endometriosis and the other of endocervicosis associated with endometriosis.The first case refers to a 38-year-old woman, ex-smoker, who had previously undergone 4 Caesarean sections but did not have any other urological history of interest.She was referred from the gynaecology department due to the finding of a nodular formation in the bladder during study of a nonviable foetus in week 22 of pregnancy. Prior to the Caesarean section, a magnetic resonance imaging (MRI) scan was performed, revealing an anterior placenta with signs of deep invasion of the myometrium related with placenta increta and a heterogeneous intensity and well defined nodular mass arising from the posterosuperior wall of the bladder of 7 × 30 × 18 mm suggestive of an endometrioma .During the surgery (performance of the Caesarean section), placenta accreta and uterine rupture were discarded, and bladder integrity was confirmed by palpation of an indurated nodule that increased the thickness of the wall in the centre of the vesicouterine angle.Cystoscopy was performed, in which a raised nodular formation was observed in the fundus of the bladder, bluish inside surrounded by a yellowish area .In view of these findings, complete transurethral resection of the lesion was carried out.Histopathological examination revealed a bladder endometrioma.The patient presently remains asymptomatic from a urological perspective, with no recurrence after 16 months of follow-up.The following case was a 64-year-old woman with a history of hypertension, insulin-dependent diabetes mellitus, dyslipidemia, primary hypothyroidism, and chronic renal failure. She had previously undergone 2 Caesarean sections.While performing renal Doppler ultrasound , a 2 cm During the resection, a solid, adenomatous mass was observed, around 2 cm in diameter with a pedunculated base, which was completely excised .Histopathological study of the specimen revealed endocervicosis with associated endometriosis.The patient remains asymptomatic from a urological point of view after 7 months of follow-up and is currently being monitored by the gynaecology department.Bladder endometriosis is characterised by the presence of endometrial tissue in the bladder detrusor muscle .It is a tissue of Müllerian origin that can present in three forms: as endometriosis, endosalpingiosis, and endocervicosis, although endometriosis is the most common form . Müllerianosis [The various forms can present alone or associated with one another; the presence of two or more of these lesions simultaneously is known asrianosis .It is estimated that urinary tract involvement in women with endometriosis is between 1 and 5% , with thThis entity was first described by Judd in 1921 ; later, It can present as a primary lesion in women who have not previously undergone gynaecological surgery or may be secondary to pelvic surgery, essentially after a Caesarean section , 10.The implantation or retrograde menstruation theory: postulated by Sampson, endometriosis is the result of the implantation and growth in the peritoneum and ovary of fragments of endometrial tissue that migrate to the abdominal cavity during menstruation through the Fallopian tubes. Retrograde menstruation is observed in 90% of women, which suggests that additional factors are required: genetic, immunological, hormonal, and environmental factors that cause susceptibility to endometriosis.The induction theory: it is not the endometrium itself that migrates but some substances released by it, which cause differentiation from mesenchymal cells present in the abdominal connective tissue.In situ development theory: according to this theory, the ectopic endometrium develops “in situ” from local tissues, including the germinal epithelium of the ovary and remnants of the Wolff and Müller ducts and from pluripotent cells present in the peritoneal serosa. This is the theory that best explains the disease for cases of atypical or prepubertal sites.Its aetiology is unclear, although there are several theories that attempt to explain its origin: the embryonic , metaplastic, and immunological theories .The implHowever, the migratory theory by retrograde menstruation through the Fallopian tubes, post-pelvic-surgery seeding, and blood or lymphatic seeding is the most widely accepted hypothesis, as occurs in our two cases in which both patients had a previous surgical history of Caesarean sections , 10.Clinical manifestations are usually nonspecific and may include pelvic pain, dysuria, tenesmus, pollakisuria, and even acute urinary retention. Haematuria may also appear, typically during menstruation, although it occurs in only 20–35% of patients. Symptoms are often exacerbated at this time , 11, 12.Urine cultures and cytology studies are generally negative. Filling defects in the bladder wall can usually be observed on ultrasound and other imaging tests , 13.Transvaginal ultrasound appears to have better diagnostic accuracy than transabdominal ultrasound for evaluating the extension towards the uterus and vesicovaginal septum. MRI allows better identification of the lesion and assessment of bladder wall infiltration .Cystoscopy enables a diagnosis to be established in 65–72% of patients, although the definitive diagnosis is histopathological. Dark blue solid lesions are usually observed, with an oedematous halo with bullae or cysts. The characteristics of these lesions generally vary throughout the menstrual cycle, both in size and in pigmentation .Transurethral resection is diagnostic and therapeutic and allows samples to be obtained for histopathological analysis. The definitive diagnosis is established by the presence of endometrial glands in the bladder wall . In the There is no consensus as regards treatment of these lesions, although their final treatment is primarily surgical , 10, 15.The choice of treatment depends on different factors, such as the size of the lesion, its location, or the number of tumours.Many surgical modalities have been used for the treatment of these lesions: transurethral resection and both open and laparoscopic partial cystectomy . EndoscoAs it is a rare entity, its evolution and prognosis have been evaluated in small case series, with clinical improvement in most patients . There mBoth bladder endometriosis and endocervicosis are rare entities with a common embryological origin. It is important to be aware of them in the differential diagnosis of benign and malignant bladder disease. Their clinical presentation may help in the suspected diagnosis of the entity. The treatment of choice is complete transurethral surgical resection, provided that the size and characteristics of the lesion allow.


Hiatal hernia (HH) is the herniation of elements of the abdominal cavity through the esophageal hiatus of the diaphragm. A giant HH with pancreatic prolapse is very rare and its causing pancreatitis is an even more extraordinary condition. We describe a case of a 65-year-old man diagnosed with acute pancreatitis secondary to pancreatic herniation. In these cases, acute pancreatitis may be caused by the diaphragmatic crura impinging upon the pancreas and leading to repetitive trauma as it crosses the hernia; intermittent folding of the main pancreatic duct; ischemia associated with stretching at its vascular pedicle; or total pancreatic incarceration. Asymptomatic hernia may not require any treatment, while multiple studies have supported the recommendation of early elective repair as a safer route in symptomatic patients. In summary, though rare, pancreatic herniation should be considered as a cause of acute pancreatitis. A high index of suspicion for complications is warranted in cases like these. Hiatal hernia (HH) refers to herniation of elements of the abdominal cavity through the esophageal hiatus of the diaphragm.The stomach is the most common organ to herniate. Other less common herniations include transverse colon, small intestine, and spleen. Herniation of the pancreas through the hiatus is an extremely rare occurrence. Pancreatic herniation leading to acute pancreatitis is an even more rare condition. In the world literature, from 1958 to 2011, 12 cases have been reported [We describe a rare case of an overtly symptomatic patient diagnosed with acute pancreatitis who was found to have herniation of the stomach, the body, and the tail of the pancreas and the first part of the duodenum.T) was 98 F, heart rate (HR) was 85/min, and the respiratory rate (RR) was 18. His abdomen was soft, with mild epigastric tenderness and normal bowel sounds. The rest of the physical exam was unremarkable.A 65-year-old Caucasian male with no known past medical history came to the emergency room (ER) complaining of abdominal pain and vomiting for 1 day. He was in his usual state of health prior to an acute onset of epigastric pain which was dull and crampy in nature, 8/10 in intensity and associated with nausea and 10–12 episodes of nonbloody vomiting. He denied any other complaints. In the ER, his blood pressure (BP) was 165/91 mm of Hg, temperature  of abdomen/pelvis with radio contrast Figures  and 2 waThe patient underwent an esophagogastroduodenoscopy (EGD) on day 4 of admission which revealed erythematous mucosa of the fundus and body of the stomach, Barrett's esophagus, and a sliding HH. Biopsy revealed squamocolumnar mucosa with mild chronic inactive inflammation and no helicobacter pylori identified. The patient refused any surgical intervention. He clinically improved and was discharged with outpatient follow-up.HH corresponds to the transient or permanent migration of the stomach through the diaphragm into the chest which may be accompanied by other abdominal organs as in this case. The most common organs to accompany the stomach are the colon , loops of small bowel, and omentum. A large HH is a hernia that includes at least 30% of the stomach in the chest. Many reports of giant HH have been published, but a giant HH with pancreatic prolapse is extremely rare . It is pHH are more common in Western countries . BurkittHH is classified into two types depending on the position of the gastroesophageal (GE) junction and the extent of herniated stomach: sliding hernias and paraesophageal hernias , 7. TypeHH may be asymptomatic or patients might complain of heartburn, belching, dysphagia, abdominal pain, nausea, chest pain, or cough. In most patients, the cause of the HH is unknown. Some people are born with a weakness or an especially large hiatus. It is believed that increased pressure in the abdomen from chronic coughing, straining during bowel movements, pregnancy and delivery, obesity, and abdominal ascites may contribute to the development of the HH. Rarely, iatrogenic or traumatic diaphragmatic hernia (DH) may occur. They account for less than 1% of all the DH . IatrogeHH can be complicated by intermittent bleeding episodes from associated esophagitis, erosions, and esophageal ulcers; iron deficiency anemia; incarceration; strangulation and perforation. Acute pancreatitis complicating a diaphragmatic hernia is rare and multiple theories have been proposed to explain it. Acute pancreatitis occurring in the case of a pancreatic hernia may be caused by repetitive trauma as it crosses the hernia, ischemia associated with stretching at its vascular pedicle, , 16, or Many diagnostic modalities are available including plain chest X-ray film, barium upper gastrointestinal series, CT imaging, and EGD. Asymptomatic hernia might not require any treatment. HH with gastroesophageal reflux disease can be managed medically. Symptomatic HH , HH with severe esophagitis, and types II, III, and IV HH might require surgical intervention which includes reduction of the hernia, closure of the hiatal defect, and antireflux procedure. Hiatal hernias can be repaired by a transabdominal or transthoracic approach . LaparosThe risk of these hernias becoming incarcerated, leading to strangulation or perforation, is approximately 5%. Elective repair often is advised in symptomatic patients. In a study by Sihvo et al. , of the Pancreatitis caused in our patient was treated with fluids, analgesia, antiemetics, and gradual advancement of diet as tolerated by the patient. Our patient did not undergo surgery since the patient only wanted conservative management at that time.Pancreatic herniation is a rare entity which may lead to even rarer complications of pancreatitis. Symptomatic herniation is best treated with surgery. Our patient's large hernia was not surgically repaired, despite our recommendations and an explanation of the potentially fatal risk. Elective surgery is found to be safer than emergent surgery in a patient that has suffered a serious complication.


Kasabach–Merritt syndrome is a benign condition characterized by hemangiomatosis, severely disseminated intravascular consumption coagulopathy, and thrombocytopenia. The mortality rate increases from 12% to 30% in hemorrhagic cases. In general, the symptoms primarily manifest in the gastrointestinal tract, the skin, and the subcutaneous tissue. There is no publication about pulmonary manifestation of angiomatosis in combination with vascular malformation and hemoptysis. This is the first description of a Kasabach–Merritt syndrome-like condition in the lung.We present the case of a 29-year-old German woman with angiomatosis and associated pulmonary vascular malformation in her lower left lobe with a Kasabach–Merritt syndrome like condition. It was detected after hemoptysis. We also present our case observations and management.In a case of angiomatosis with an associated pulmonary lobar vascular malformation, lobectomy can be safely performed to prevent life-threatening bleeding. Angiomatosis is defined as a diffuse proliferation of well-developed blood vessels. It is a benign condition, continuously affecting a large segment of the body. Formerly classified as neoplasm, it is currently defined as vascular malformation. Approximately two-thirds of the cases manifest in the first 2 decades of life . KasabacThe etiology of the KMS remains unclear. It has been hypothesized that exposure of the subendothelial elements or abnormal endothelium within the hemangioma results in aggregation and activation of platelets with a secondary consumption of clotting factors ,3,5,6. TA 29-year-old German woman was admitted to our hospital with a history of hemoptysis a few days before admission. She did not report severe coughing, emesis, or extraordinary physical stress. She had been admitted to another hospital 15 years ago because of significant gastrointestinal bleeding caused by esophageal varices of 2nd to 3rd degree. A preoperative computed tomography (CT) scan showed an upper abdominal mass with a potential infiltration of her liver. Furthermore, a thrombosis of her portal vein and a partial thrombosis of her superior mesenteric vein were detected. She displayed a splenomegaly with a strong lienal vein and a paravertebral vascular plexus. She therefore underwent laparotomy. During surgery, the lesion was diagnosed as a hemangiomatosis of the greater omentum, extending through the hepatoduodenal ligament to the left lobe of her liver; varicose veins of her entire stomach wall were also detected. Because of this extension, the lesion was classified as non-resectable. A biopsy Figure . These fThe presented case reflects the condition of an abdominal angiomatosis with associated solitary vascular malformation of the lung and KMS-like characteristics. The most frequent sites involved with angiomatosis are the lower extremities; followed by the chest wall, the abdomen and upper extremities . Most reNumerous therapeutic approaches are available for the treatment of KMS. Various nonsurgical therapies have been reported for the treatment of hemangioma, such as corticosteroids, IFN-α, vincristine, and radiotherapy (RT); however, their use is limited due to their side effects . One of Corticosteroids are often used in combination with RT, IFN-α, or surgery. IFN-α inhibits angiogenesis by suppressing overexpression of the basic fibroblast growth factor, an angiogenic protein, in infantile hemangiomas. Fost and Esterly  treated In the past, RT was the treatment of choice for hemangiomas and KMS. Approximately 85% of the cases of hemangioma treated with RT prior to 1960 showed complete resolution, whereas 15% showed considerable improvement. On occasion, hemangiomas are resistant to RT [In a case of angiomatosis with an associated pulmonary lobar vascular malformation, lobectomy can be a promising option to prevent life-threatening bleeding.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.


We began to decompress the small intestine and administer octreotide. However, the intestinal obstruction did not improve. Although intestinal pseudo-obstruction caused by limited SSc was considered as a differential diagnosis, we performed an exploratory laparotomy because the possibility of peritoneal dissemination-associated obstruction could not be excluded. We observed a moderate amount of serous ascites and dilatation of the small intestine that was white in color, hard, and with limited contractility. There was no evidence of peritoneal dissemination nor of mechanical obstruction. Our experience thus shows the difficulty of distinguishing SSc-associated intestinal pseudo-obstruction from peritoneal dissemination.A 78-year-old woman receiving treatment for limited systemic scleroderma (SSc) underwent high anterior resection and partial liver resections for rectosigmoid colon cancer with multiple liver metastases. A year after surgery, an abdominal computed tomography (CT) demonstrated suspicion for peritoneal dissemination with an increase in ascites, and  Systemic scleroderma (SSc) is a chronic disorder of the connective tissue characterized by inflammation, fibrosis, and degeneration of the skin and blood vessels and is known to cause intestinal pseudo-obstruction -5. The rcurrence -12. We rA 78-year-old woman receiving treatments including the administration of low dose of corticosteroid and proton pump inhibitor for LSSc  for 7 years underwent high anterior resection and partial liver resections for rectosigmoid colon cancer with multiple liver metastases . The preoperative serum levels of carcinoembryonic antigen (CEA) and carbohydrate antigen CA19-9) were 7.9 ng/ml  and 85.7 U/ml . Pathological findings showed well-differentiated tubular adenocarcinoma, T3N1M1 with lymphatic invasion. On partial resection for each liver metastasis, S4 lesion resulted in positive resection margin. Although she received adjuvant therapy  for 6 months after surgery, she stopped the therapy because of the side effects. A year after the surgery, an abdominal CT demonstrated suspected peritoneal dissemination with increased ascites (Figure 9-9 were Gastrointestinal involvement is the most common non-dermatologic complication in patients with SSc ,13. GastOn radiographic examination, abdominal X-ray did not show the typical appearance of SSc-associated pseudo-obstruction such as the hide-bound bowel sign ,6-8. AltIn conclusion, our experience suggests that it is difficult to distinguish LSSc-associated intestinal pseudo-obstruction from peritoneal dissemination. Although FDG PET-CT is an effective tool for detection of peritoneal metastasis, comprehensive assessment of the findings in a patient with both SSc and advanced gastrointestinal cancer is necessary.Written informed consent was obtained from the patient’s husband 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.


Medial tibial stress syndrome is one of the most common causes of exertional leg pain in runners whereas musculoskeletal tumors and tumor-like lesions are rare encounters in orthopedic sports medicine practice.Unicameral (simple) bone cyst is a well-known tumor-like lesions of the bone typically affecting children and adolescents. Bilateral occurrence is very rare though and has never been reported before in both tibiae. Failing to accurately diagnose a tumorous lesion can entail far-reaching consequences for both patients and physicians.We report the case of large bilateral unicameral bone cysts of the diaphyseal tibiae mimicking medial tibial stress syndrome in a 17-year old professional athlete. This is the first report of symmetric tibial unicameral bone cysts in the literature. The patient complained about persisting shin splint-like symptoms over 5 months despite comprehensive conservative treatment before MRI revealed extensive osteolytic bone lesions in both diaphyseal tibiae. The patient-tailored, less-invasive surgical procedure, allowing the patient to return to his competitive sports level symptom-free 3 months after surgery and to eventually qualify for this years Biathlon Junior World Championships, is outlined briefly. Pathogenesis and various treatment options for this entity will be discussed.This report will help to raise awareness for musculoskeletal tumors as differential diagnosis for therapy-refractory symptoms in young athletes and encourage medical staff involved in sports medicine and athlete support to perform early high quality imaging and initiate sufficient surgical treatment in similar cases. Moreover, our less-invasive surgical procedure aiming for a fast return to sports might be an optimal compromise between traditional open curettage with low risk of recurrence and a soft tissue-saving and bone-sparing minimal-invasive technique. Medial tibial stress syndrome (MTSS), commonly known as ‘shin splints’, is one of the most common causes of exertional leg pain in runners. It is believed to be caused by a multifactorial spectrum of stress injuries including periostitis, tendinopathy, periosteal remodeling and stress reaction of the tibia . DiagnosUnicameral (simple) bone cyst (UBC) is a common tumor-like lesions of the bone. There is a strong predilection for the long bones of the proximal humerus and proximal femur, accounting for up to 85 % of all cases. Symptomatic cysts are typically observed between 5 and 15 years of age with a male predominance in a ratio of 3:1 . With skA 17-year old male professional runner was transferred to our musculoskeletal tumor centre on recommendation from his team doctor. Currently a member of a national biathlon junior team, the patient was one of the best track and field athletes of his age group for mid-distance running disciplines 1500 m & 3000 m) on a competitive level at the time of initial diagnosis. Besides daily workout in the gym for strentgh and endurance, his training schedule included up to 4 h running 6 days per week. However, ongoing pain in both of his shins prevented the young athlete from training and competition despite intensive conservative treatment for 5 months. Before admission to our hospital, symptoms were treated for shin splints without success until MRI was conducted. Extensive cyst-like bone lesiosn were found in both diaphyseal tibiae Figs. . Imaging000 m on As multimodal conservative treatment for MTSS demonstrated unsuccessful and MRI revealed the most likely reason for the patient’s symptoms, surgical therapy was indicated after thorough analysis of all clinical and radiological findings. In favour of a fast return to a competitive sports level we abandoned our standard surgical procedure for UBC consisting of open curettage and autologous cancellous bone grafting from the iliac crest. Due to the dimensions of both tibial lesions, this would have been associated with a long recovery and potential major donor site morbidity both seriously jeopardizing the young athlete’s competitive sports career. Based on promising reports of minimally invasive surgery for treatment of UBC of the humerus from Hou et al. , 8 we peHistopathologic examination confirmed the diagnosis of UBC. Microbiology results of the smear test showed no signs of bacterial infection. After complete wound healing the patient was allowed to resume modest physical activity with cycling and swimming to regain muscular strength and decrease muscle atrophy. Six months after initial surgery on the left tibia and 3 months after last surgery on the contralateral right side the athlete had regained his full training capacity on a competive level and has been free of symptoms eversince. Clinical and radiographic follow-ups showed desirable bony consoldidation of the tibiae without signs of recurrence Figs.  and 7. TEtiology of UBC remains unknown. Among the accepted theories is the concept described by Cohen  in 1960 Regarding potential etiologic factors in the case described excessive workout during a period of rapid bone growth repetetively creating bony micro-lesions of the bone and causing a disturbance of hydrostatic pressure might have contributed to the development of UBC. Nevertheless UBC of bones of the lower extremity is not a common disorder encountered regularly in young athletes and such bilateral occurence of both tibiae is still unreported. Also other etiologic considerations have to be taken into account: Low-grade osteomyelitis as well as tumors and tumor-like lesions of the bone are suspected to act as precursor-lesion for the origination of UBC by some authors –18. BilaTherapeutically, radical excision of the cyst reduces the rate of recurrence but increases morbidity and complication rate . Some auThis is, to our best knowledge, the first report of bilateral diaphyseal simple bone cysts of the tibiae. There have been reports of two or more unicameral bone cysts in the same patient at different locations , 21 and Medial tibial stress syndrome (MTSS) or ‘shin splints’ is a common reason for excercise-related pain of the lower leg in young athletes, especially in running disciplines. Unless futher investigated by radiologic imaging, relevant differential diagnoses of shin splints can remain undetected. Musculoskeletal tumors and tumor-like lesions are rare encounters in sports medicine practice but have to be taken into consideration in any patient with therapy-refractory symptoms, especially in young patients. High vigilance to recognize tumor-related findings is necessary for any physician not routinely dealing with tumor orthopaedics. Additional diagnostics and definite therapy of suspicious musculoskeletal lesions should be performed in a highly experienced musculoskeletal tumor centre to prevent misdiagnosis and initiate individual treatment if required. Diagnostic errors may entail serious consequence not only for a future career in professional sports but also for life and limb of the affected patient.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 of this journal.


Case Presentation. A 54-year-old female came to our attention with dysphagia and dyslalia of 6-month standing. Ear, Nose, and Throat (ENT) examination revealed a voluminous mass on the right portion of the base of her tongue, where postcontrast T2-weighted Magnetic Resonance Imaging (MRI) evidenced a hyperintense lesion. The fine-needle aspiration specimen taken for cytology was not diagnostic, as a differential diagnosis between myoepithelioma and a malignant neoplasm of the salivary glands necessitates parameters that cytology alone cannot provide. Therefore, the whole lesion was excised by diode laser through a transoral approach. Histology and immunohistochemistry of the completely excised lesion confirmed a myoepithelioma. Myoepithelioma is an extremely rare tumour subtype and diagnosis is based on a wide variation of cellular morphology. FNAC specimens do not always suffice for a definitive differential diagnosis which depends on histology and immunohistochemistry of the lesion. Myoepithelioma is a rare benign myoepithelial tumour and its malignant counterpart is myoepithelial carcinoma. It is normally located in the major salivary glands; in fact myoepitheliomas arising from minor salivary glands are very rare, representing only 1.5% of all salivary gland tumours, and the base of the tongue is an unusual location . Myoepitα-smooth muscle actin  showed remarkable enhancement of the mass . Fine-nele actin . A Core  and p63 . These fα-smooth muscle actin (SMA). Although most myoepitheliomas are biologically benign, malignant transformation of epithelioid myoepithelioma has been recently described; moreover, it occasionally infiltrates locally and metastasizes. Histological examination of the surgical specimen is still the gold standard to reach a definitive diagnosis of malignancy, due to the fact that it is based primarily on its infiltrative growth and, as cytological atypia may be absent in carcinomas, cytology alone does not suffice. In these cases, transmucosal Core Needle Biopsy (CNB) can be of great help for diagnosis but requires general anesthesia, experience of the surgeon, and a good exposure of the lesion [Myoepithelioma and its malignant counterpart, myoepithelial carcinoma, of the salivary glands are neoplasms made up almost exclusively of tumour cells with myoepithelial differentiation . Their de lesion . The pree lesion . It is ae lesion . We perf


A 44-year-old male presented with progressing cough, dyspnea and hemoptysis due to a tracheal tumor involving the posterior wall of the lower trachea, with severe airway obstruction and coagulopathy. Consequently the patient underwent segmental resection of the trachea with an end-to-end anastomosis. Twenty months after treatment there remained no evidence of endobronchial recurrence at bronchoscopy or imaging studies. The diagnosis was benign tracheal glomus tumor (GT) which is an exceedingly rare mass lesion in the trachea. There are three subtypes: GT proper, glomangioma and glomangiomyoma. The present study describes the clinical and pathological features of glomangioma through a case report and literature review. To the best of our knowledge, this is the fifth report of glomangioma subtype arising from the trachea. Glomus tumors (GTs) are neoplasms arising from the modified smooth muscle cells surrounding arteriovenous anastomosis ,2. GT isA 44-year-old male, exhibiting a defined tracheal tumor that was diagnosed by the local hospital  two months earlier, was admitted to our hospital  due to acute respiratory distress. The patient had suffered from cough, expectoration and dyspnea without any evident incentive for >1 year. Six days before admission, the symptoms were aggravated with hemoptysis. A chest X-ray scan was found to be normal. However, a computed tomographic (CT) scan revealed a demarcated homogenous intratracheal mass at the layer of the superior border of the manubrium . FlexiblTo prevent mortality and restore the airway, endotracheal intubation was conducted initially using a rigid tracheoscope under surface anesthesia. Due to the unstable condition of the patient, comprehensive treatment was administered to prepare for the operation. A preoperative coagulation profile revealed prolonged activated partial thromboplastin time  and prothrombin time , which indicated an increased risk for the surgery. With plasma transfusion, after five days the patient underwent segmental resection of the trachea with an end-to-end anastomosis and the bilateral pulmonary infection led to a poor general postoperative condition. Due to being bed-ridden postoperatively, 13 days following the surgery the patient exhibited femoral and deep vein thrombosis. Thrombolytic therapy was challenging, due to the persistent bleeding disorder. To prevent pulmonary embolus, vena cava filters were placed and clot-busting therapy was conducted simultaneously. The patient was discharged without the support of ventilation 26 days after presentation. Three months after resection, the patient underwent follow-up with CT and endoscopy to exclude focal recurrence or suspicious metastasis. The lumen of the trachea remained clear for 20 months after the surgery.The surgical specimen was ~2 cm in length, with a luminal diameter of 2.5 cm. The specimen exhibited a 3×2.5×1 cm red-brown mass sessile in the posterior wall of the trachea, which occupied the lumen as a polypoid mass . MicroscGTs are uncommon mesenchymal neoplasms. The etiology of these tumors remains a conundrum, and certain individuals attribute GTs to trauma, endocrine disorder or autosomal dominant inheritance ,2. Murraet al, the round glomus cells represented the largest component of tumor cells surrounding the thin-walled vascular spaces, leading to the hypothesis that this may be a subtype of glomangioma (To the best of our knowledge, no malignant GTs have been described in the trachea thus far. The histological morphology varies in subtypes according to the relative proportions of the glomus cells, vascular structures and smooth muscle tissue ,33. In amangioma . Based omangioma ,32,33. GTo avoid local recurrence, tracheal resection is widely used and exhibits favorable prognosis . EndoscoFurthermore, as an uncommon site, treating the complications and accompanying diseases during the perioperative period is crucial in order to increase survival rates. The main cause of mortality reported in the literature following surgery was not the primary tumor or the procedure but the complications ,10. The In conclusion, previous studies and the present report reveal that the incidence of GTs in the trachea is low and these tumors primarily occur in males, with unknown etiology and concealed onset. Patients with GTs usually resort to medical attention for symptoms of airway obstruction. CT imaging, magnetic resonance imaging and flexible bronchoscopy of GTs reveal a lumen-occupying lesion. Surgical management is generally the primary option and histopathological examination may determine the diagnosis. The long-term prognosis of the disease is promising.


To The Editor: Monomicrobial liver abscesses caused by Klebsiella pneumoniae are an emerging problem in Asia. Among 77 capsular types of Klebsiella spp., K1 and K2 are the most virulent . Ceftriaxone was administered, in accordance with an antibiogram, but the patient’s condition worsened and he required mechanical ventilation and treatment with a catecholamine in an intensive care unit. A computed tomographic (CT) scan showed 2 liver abscesses and infiltrates of both lungs with pleural effusion  and liver enzymes were increased . An initial chest radiograph and abdominal ultrasonograms were unremarkable. effusion . Under CK. pneumoniae was cultured from the liver punctate as well as from the urine. The isolate proved to be serotype K2. Multilocus sequencing of this strain confirmed the presence of the wzx2 and wzy2 genes. In accordance with susceptibility test results, therapy with ceftriaxone and ciprofloxacin was initiated. Dislocation of the pigtail catheter resulted in an abscess of the abdominal wall, which required additional surgical treatment. However, the patient recovered within 2 weeks. Follow-up CT images showed resolution of the thoracic lesion and only a residual scar on the liver lobe , blood count and liver enzymes within reference range, and a urinary tract infection positive for nitrite and leukocytes (500/μL). Abdominal ultrasonography revealed a 3 × 4-cm subcapsular lesion in the left lobe of the liver, highly suspect for metastatic spread of an unknown tumor. Chest radiographs, taken in search of the primary lesion, revealed a lesion in the right upper lung; on follow-up CT images, this lesion was suspect for malignancy . For diaver lobe . K. pneumoniae serotype K1 and K2 liver abscesses with metastatic spread to the lung and urinary systems in previously healthy white patients from Germany differ from previously published cases. These 2 patients were not of Asian ethnicity and had no travel history, no contact with persons in a high-risk group  and PCR of the


Primary malignant lymphoma of the breast (PLB) is a rare disease. Treatment options include surgical resection, systemic chemotherapy, radiation and immunotherapy. At present, the optimum treatment combination remains controversial. The present study reports the case of a 39-year-old female with a six month history of a painless mass in the left breast. The mass was excised following medical examination. A diagnosis of diffuse large B-cell lymphoma was determined as a result of histological and immunohistochemical profile analysis. Further examinations excluded metastatic disease. Thus, finally, PLB (diffuse large B-cell lymphoma type) was diagnosed. The patient was treated with adjuvant systemic chemotherapy and consolidated radiation and a positive response was observed. During the 10 months of follow-up, no evidence of disease recurrence was identified. At present, the patient is scheduled for regular follow-up appointments. As the prevalence of PLB is increasing, the details of this rare case may aid clinicians treating similar patients, and highlight the importance of this disease. Primary malignant lymphoma of the breast (PLB) is a rare disease, which accounts for only 0.4–0.5% of all breast malignancies, 0.38–0.7% of all non-Hodgkin’s lymphomas (NHLs) and 1.7–2.2% of extranodal NHLs in the caucasian population . Current2, day 1), intravenous doxorubicin , intravenous vincristine  and prednisone ] for six months. Following three cycles of chemotherapy, radiation was adminstered to the local site (40 Gy), in combination with chemotherapy for an additional three cycles. The patient exhibited a positive response with no evidence of disease. During the follow-up period of 10 months, no symptoms or signs of disease recurrence were observed. At present, the patient is receiving regular follow-up.In April 2013, a 39-year-old female presented to the Department of Surgery, Suining Central Hospital  with a six month history of a painless mass in the left breast. The mass had rapidly increased in size over six months. No history of other diseases was identified. On physical examination, a nontender, demarcated firm 5.0×5.0 cm elastic mass with an irregular surface, was palpable in the upper inner quadrant of the left breast. The right breast was normal. Enlargement of the axillary lymph nodes was not identified. On ultrasonography, the mass was observed to be solid, almost entirely hyperechoic, and exhibited a circumscribed margin in the palpable area. Digital radiographic examination revealed a mass of 5.0×4.0×4.0 cm with an increased density shadow . The radPLB remains a rare disease, however, the occurrence is increasing due to improvements to diagnostic techniques and increasing awareness of the disease. The criteria for PLB diagnosis have been defined by Wiseman and Liao , and incTo date, no standard treatment for PLB has been identified. Mastectomy is not indicated and wide local excision is not required as these tumors are highly sensitive to radiotherapy and systemic chemotherapy . In a prHowever, the majority of studies have been descriptive studies and thus, detailed studies exploring the molecular mechanisms of PLB are urgently required. A number of hypotheses have been proposed to explain the pathogenesis of PLB. Hormonal stimulation may be an important factor as PLB was observed frequently in women during pregnancy or postpartum . In maleIn conclusion, this study reports a rare case of a female with PLB presenting as a painless mass in the left breast. As the clinical symptoms of PLB are diverse and nonspecific, misdiagnosis as other breast diseases may occur. Overall, PLB is rare, however, the prevalence is increasing. Therefore, this disease requires attention. The early diagnosis and timely treatment are important factors when treating PLB. Furthermore, additional studies focusing on the etiology and mechanism of PLB are required.


Urachal cyst is an unusual clinical condition, which is usually asymptomatic. In some adult cases, it may lead to complications. The cyst is between umbilicus and urinary bladder. It is diagnosed via ultrasonography and computed tomography. However, in some cases, the diagnosis is made by means of surgical exploration and histopathological evaluation. In this paper, we report a case of a 17-year-old female presenting with painful abdominal mass. At the first evaluation, the case was diagnosed as a mesenteric cyst because the mass located in the mesentery, and final histopathological report revealed the urachal cyst. The urachus is an embryonic connection between the urinary bladder and the allantois. It obliterates during early infancy, to form the median umbilical ligament between the transverse fascia and the peritoneum. Histologically, the inner layer is modified transitional epithelium, the middle is fibroconnective tissue, and the outer layer is a smooth muscle layer . If uracA 17-year-old female suffered from periumbilical pain. She had a history of tonsillectomy and was still taking pantoprazole for epigastric pain. There was no complaint related to the urinary system. In the physical examination, there was a palpable painful mass, approximately 5 cm in diameter, at the posterior of the umbilical region. The laboratory tests were within normal limits. On abdominal ultrasonography (US) and abdominal computed tomography (CT), a cystic mass was seen in the posterior of the umbilical region, extending towards the left side, 41 × 39 mm in size . With thThe most frequent form of urachal anomalies is urachal cyst at rates of 30% and it is more frequent in males. Unless complications develop in urachal cysts, they are small, silent, and asymptomatic. Complications may include infection, bleeding within the cyst, enlargement, intraperitoneal rupture, intestinal fistula, intestinal obstruction, lithiasis, and a high incidence of malignant degeneration . There mIn the differential diagnosis, vitelline duct anomalies, appendicitis, granulomatous inflammations, and granulation tissue from the umbilical stump should be kept in mind . In our In the treatment of urachal anomalies in adults, recurrence occurs at rates of 31% when treatment is made by drainage rather than by conservative treatment . In addiAlthough urachal anomalies are rarely seen, complete surgical application is required due to the high incidence of recurrence and malignancy in adult patients. Despite pediatric surgery and urology clinic interventions, when there is a urachal cyst, as in the current case, it is one of the probable pathologies encountered by general surgeons as an intra-abdominal mass. Sometimes, its diagnosis is possible with surgical exploration or histopathological evaluation like our patient.